Healthcare Provider Details

I. General information

NPI: 1184874646
Provider Name (Legal Business Name): ANNE MICHELLE KUKRAL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2008
Last Update Date: 09/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1ST AVE AT 16TH STREET BIMC PETRIE DIVISION
NEW YORK NY
10003
US

IV. Provider business mailing address

325 W 108TH ST APT 4B
NEW YORK NY
10025-2735
US

V. Phone/Fax

Practice location:
  • Phone: 212-420-4623
  • Fax: 212-420-2912
Mailing address:
  • Phone: 212-666-6351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number004103
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: