Healthcare Provider Details

I. General information

NPI: 1669032116
Provider Name (Legal Business Name): PRISCELA LIZETTE KUGBLENU PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2019
Last Update Date: 06/01/2023
Certification Date: 06/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 ALBANY SHAKER RD
LOUDONVILLE NY
12211-1900
US

IV. Provider business mailing address

106 N PINE AVE APT 2
ALBANY NY
12203-1737
US

V. Phone/Fax

Practice location:
  • Phone: 518-435-1300
  • Fax:
Mailing address:
  • Phone: 518-512-6321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number025029
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: