Healthcare Provider Details

I. General information

NPI: 1023482700
Provider Name (Legal Business Name): DIANA KUDERNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2015
Last Update Date: 11/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2223 MCKINLEY AVE
BERKELEY CA
94703-1717
US

IV. Provider business mailing address

2223 MCKINLEY AVE
BERKELEY CA
94703-1717
US

V. Phone/Fax

Practice location:
  • Phone: 510-541-0226
  • Fax:
Mailing address:
  • Phone: 510-541-0226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA17761
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: