Healthcare Provider Details

I. General information

NPI: 1447403191
Provider Name (Legal Business Name): CHRISTOPHER KUDRICH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2008
Last Update Date: 06/25/2024
Certification Date: 06/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1399 PARK AVE
NEW YORK NY
10029-4567
US

IV. Provider business mailing address

406 PIERCE AVE
ARCHBALD PA
18403-1559
US

V. Phone/Fax

Practice location:
  • Phone: 212-585-4672
  • Fax:
Mailing address:
  • Phone: 570-947-5272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number012834
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: