Healthcare Provider Details

I. General information

NPI: 1366432379
Provider Name (Legal Business Name): JOANN KUNUGI PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 1ST ST
ALAMOSA CO
81101-2302
US

IV. Provider business mailing address

1710 1ST ST
ALAMOSA CO
81101-2302
US

V. Phone/Fax

Practice location:
  • Phone: 719-589-3658
  • Fax: 719-589-0997
Mailing address:
  • Phone: 719-589-3658
  • Fax: 719-589-0997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number466
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: