Healthcare Provider Details

I. General information

NPI: 1972887842
Provider Name (Legal Business Name): KRISTINA LEIGH KUPRYK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2011
Last Update Date: 10/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 DIAMOND BRIDGE AVENUE
HAWTHORNE NJ
07506
US

IV. Provider business mailing address

169 HILLCREST DR
WAYNE NJ
07470-5629
US

V. Phone/Fax

Practice location:
  • Phone: 973-427-0600
  • Fax:
Mailing address:
  • Phone: 862-226-1149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number25MP00266800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: