Healthcare Provider Details

I. General information

NPI: 1346133022
Provider Name (Legal Business Name): EMILY GRACE KUGEMAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2025
Last Update Date: 05/31/2025
Certification Date: 05/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 WOODSIDE AVE APT 3
JAMAICA PLAIN MA
02130-4940
US

IV. Provider business mailing address

21 WOODSIDE AVE APT 3
JAMAICA PLAIN MA
02130-4940
US

V. Phone/Fax

Practice location:
  • Phone: 203-394-2108
  • Fax:
Mailing address:
  • Phone: 203-394-2108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: