Healthcare Provider Details

I. General information

NPI: 1578281820
Provider Name (Legal Business Name): KAITLIN TAYLOR KUCERA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2022
Last Update Date: 06/19/2025
Certification Date: 06/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 E VILLA MARIA RD STE A
BRYAN TX
77802
US

IV. Provider business mailing address

2010 E VILLA MARIA RD STE A
BRYAN TX
77802-2583
US

V. Phone/Fax

Practice location:
  • Phone: 979-731-5200
  • Fax: 979-821-7631
Mailing address:
  • Phone: 979-731-5200
  • Fax: 979-821-7631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA18368
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: