Healthcare Provider Details

I. General information

NPI: 1285292680
Provider Name (Legal Business Name): KRISTOPHER E KUSZAK PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2019
Last Update Date: 02/01/2021
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 OTTAWA RD
NEODESHA KS
66757-1897
US

IV. Provider business mailing address

PO BOX 360
NEODESHA KS
66757-0360
US

V. Phone/Fax

Practice location:
  • Phone: 620-325-2611
  • Fax:
Mailing address:
  • Phone: 620-325-2622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number15-02258
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: