Healthcare Provider Details

I. General information

NPI: 1376815795
Provider Name (Legal Business Name): CASSANDRA MARIE KUCH ANDERSON P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2012
Last Update Date: 05/04/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1122 BROADWAY
WOODMERE NY
11598-1242
US

IV. Provider business mailing address

1122 BROADWAY
WOODMERE NY
11598-1242
US

V. Phone/Fax

Practice location:
  • Phone: 516-295-3838
  • Fax:
Mailing address:
  • Phone: 516-295-3838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number013595-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: