Healthcare Provider Details

I. General information

NPI: 1467881102
Provider Name (Legal Business Name): JAMES KEMAH KUKWA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2013
Last Update Date: 11/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1670 ENGLISH ST
SAINT PAUL MN
55106-1129
US

IV. Provider business mailing address

1670 ENGLISH ST
SAINT PAUL MN
55106-1129
US

V. Phone/Fax

Practice location:
  • Phone: 652-262-7877
  • Fax:
Mailing address:
  • Phone: 652-262-7877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: