Healthcare Provider Details

I. General information

NPI: 1336839307
Provider Name (Legal Business Name): LEARTA KUKAJ PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2023
Last Update Date: 05/11/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 PALMER AVE
BRONXVILLE NY
10708-3403
US

IV. Provider business mailing address

7501 RIDGE BLVD APT 1A
BROOKLYN NY
11209-2928
US

V. Phone/Fax

Practice location:
  • Phone: 646-697-4727
  • Fax:
Mailing address:
  • Phone: 917-370-7437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: