Healthcare Provider Details

I. General information

NPI: 1770360141
Provider Name (Legal Business Name): MATTHEW DANIEL KUKAWSKI PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2023
Last Update Date: 10/06/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44201 DEQUINDRE RD
TROY MI
48085-1117
US

IV. Provider business mailing address

26901 BEAUMONT BLVD STE 3D
SOUTHFIELD MI
48033-3849
US

V. Phone/Fax

Practice location:
  • Phone: 248-964-0535
  • Fax:
Mailing address:
  • Phone: 947-522-1863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601012018
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: