Healthcare Provider Details

I. General information

NPI: 1811312523
Provider Name (Legal Business Name): ANDREW KUKLA M.ED, A.T.,C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2014
Last Update Date: 03/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 MAIN ST KENNEDY HOUSE
LAWRENCEVILLE NJ
08648-1600
US

IV. Provider business mailing address

2500 MAIN ST KENNEDY HOUSE
LAWRENCEVILLE NJ
08648-1600
US

V. Phone/Fax

Practice location:
  • Phone: 814-504-2037
  • Fax:
Mailing address:
  • Phone: 814-504-2037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number25MT00152600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: