Healthcare Provider Details

I. General information

NPI: 1174861405
Provider Name (Legal Business Name): ACKSA CHACKO KUCHARYSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2013
Last Update Date: 01/21/2025
Certification Date: 01/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1314 OAK ST
MELBOURNE FL
32901-3111
US

IV. Provider business mailing address

1314 OAK ST
MELBOURNE FL
32901
US

V. Phone/Fax

Practice location:
  • Phone: 321-727-7992
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9110285
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9110285
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601006555
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: