Healthcare Provider Details

I. General information

NPI: 1952899619
Provider Name (Legal Business Name): NATHAN ROBERT KUKOWSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2018
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 J DEWEY GRAY CIR
AUGUSTA GA
30909-1867
US

IV. Provider business mailing address

3650 J DEWEY GRAY CIR
AUGUSTA GA
30909-1867
US

V. Phone/Fax

Practice location:
  • Phone: 706-863-9797
  • Fax: 706-860-7686
Mailing address:
  • Phone: 68-639-7977
  • Fax: 706-860-7686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number99362
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number99362
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: