Healthcare Provider Details

I. General information

NPI: 1003342197
Provider Name (Legal Business Name): ERIC JOHN KUTAY RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2017
Last Update Date: 05/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4531 NORTHWAY RD
WILLIAMSPORT PA
17701-8494
US

IV. Provider business mailing address

4531 NORTHWAY RD
WILLIAMSPORT PA
17701-8494
US

V. Phone/Fax

Practice location:
  • Phone: 570-435-2570
  • Fax:
Mailing address:
  • Phone: 570-435-2570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberRN597353
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: