Healthcare Provider Details

I. General information

NPI: 1508062712
Provider Name (Legal Business Name): SARAH J KUDELKO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 04/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

987 BOARDMAN CANFIELD RD
BOARDMAN OH
44512-4222
US

IV. Provider business mailing address

3968 NEW CASTLE RD 2
PULASKI PA
16143-1231
US

V. Phone/Fax

Practice location:
  • Phone: 330-965-8760
  • Fax:
Mailing address:
  • Phone: 724-528-1939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.002330
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA052535
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: