Provider Demographics
NPI:1043908619
Name:PUPO, ROGER MANUEL
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:MANUEL
Last Name:PUPO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6601 MEMORIAL HWY STE 112
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-4501
Mailing Address - Country:US
Mailing Address - Phone:727-353-3446
Mailing Address - Fax:727-353-3447
Practice Address - Street 1:6601 MEMORIAL HWY STE 112
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-4501
Practice Address - Country:US
Practice Address - Phone:727-353-3446
Practice Address - Fax:727-353-3447
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-01
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11026070363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily