Healthcare Provider Details

I. General information

NPI: 1841217403
Provider Name (Legal Business Name): WABANANG GAIASHKIBOS KUCZEK MPH, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SAINT MICHAELS DR
SANTA FE NM
87505-7615
US

IV. Provider business mailing address

16 CLOUD MARCH E
SANTA FE NM
87506-2171
US

V. Phone/Fax

Practice location:
  • Phone: 505-473-6918
  • Fax: 505-473-6467
Mailing address:
  • Phone: 505-989-1893
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2003-0044
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: