Healthcare Provider Details

I. General information

NPI: 1437636792
Provider Name (Legal Business Name): KRISTIN KUKALIS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2018
Last Update Date: 07/27/2021
Certification Date: 07/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1382 OLD FREEPORT RD
PITTSBURGH PA
15238-3159
US

IV. Provider business mailing address

1382 OLD FREEPORT RD
PITTSBURGH PA
15238-3159
US

V. Phone/Fax

Practice location:
  • Phone: 412-967-1192
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA059906
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: