Healthcare Provider Details

I. General information

NPI: 1174146245
Provider Name (Legal Business Name): CHELSEA CATHERINE KUCKOVIC PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2020
Last Update Date: 12/10/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15812 E INDIANA AVE
SPOKANE VALLEY WA
99216-1875
US

IV. Provider business mailing address

611 N IRON BRIDGE WAY
SPOKANE WA
99202-4932
US

V. Phone/Fax

Practice location:
  • Phone: 509-444-8200
  • Fax:
Mailing address:
  • Phone: 509-444-8888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number61357051
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: