1174146245 NPI number — CHELSEA CATHERINE KUCKOVIC PA-C

Table of content: CHELSEA CATHERINE KUCKOVIC PA-C (NPI 1174146245)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174146245 NPI number — CHELSEA CATHERINE KUCKOVIC PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KUCKOVIC
Provider First Name:
CHELSEA
Provider Middle Name:
CATHERINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174146245
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1605 S VERA CREST DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPOKANE VALLEY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99037-9036
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-779-8351
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 NICHOLIS STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAVENPORT
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99122-9729
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-725-7501
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/24/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 61357051 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)