Provider Demographics
NPI:1174523856
Name:PUCKETT, ANDREW GRANT (DPM)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:GRANT
Last Name:PUCKETT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:827 W WYOMING ST
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-3961
Mailing Address - Country:US
Mailing Address - Phone:610-432-6221
Mailing Address - Fax:
Practice Address - Street 1:827 W WYOMING ST
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-3961
Practice Address - Country:US
Practice Address - Phone:610-432-6221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC005521213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Not Answered213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018704060001Medicaid
PA003566Medicare ID - Type Unspecified
PAU88416Medicare UPIN