Healthcare Provider Details

I. General information

NPI: 1386770386
Provider Name (Legal Business Name): CATHY ANN KUKULA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 10/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2825 LIVERNOIS RD
TROY MI
48083-1214
US

IV. Provider business mailing address

6986 RAWLING DR
WASHINGTON MI
48094-2488
US

V. Phone/Fax

Practice location:
  • Phone: 248-680-2060
  • Fax: 248-680-2099
Mailing address:
  • Phone: 586-258-8206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMI56002120
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: