Healthcare Provider Details

I. General information

NPI: 1215096946
Provider Name (Legal Business Name): GARY KUKURA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 09/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9961 SIERRA AVE
FONTANA CA
92335-6720
US

IV. Provider business mailing address

9961 SIERRA AVE
FONTANA CA
92335-6720
US

V. Phone/Fax

Practice location:
  • Phone: 909-427-3910
  • Fax:
Mailing address:
  • Phone: 909-427-3910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10381
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: