Basic Information
| Provider Information | |||||||||
| NPI: | 1093200107 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PUCKETT | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | ADDISON | ||||||||
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| Credential: | RNC-NIC, MSN, NNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5430 FREDERICKSBURG RD STE 508 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782293561 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105418281 | ||||||||
| FaxNumber: | 2105419123 | ||||||||
| Practice Location | |||||||||
| Address1: | 5430 FREDERICKSBURG RD | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002433839 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2018 | ||||||||
| LastUpdateDate: | 01/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WN0002X | 813526 | TX | N | Nursing Service Providers | Registered Nurse | Neonatal Intensive Care | 363LN0000X | AP138325 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal |
No ID Information.