Provider Demographics
NPI:1043612641
Name:KUECKER, KAYTLYN D (PA-C)
Entity Type:Individual
Prefix:
First Name:KAYTLYN
Middle Name:D
Last Name:KUECKER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KAYTLYN
Other - Middle Name:NICHOLE
Other - Last Name:DUTTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:333 N SANTA ROSA
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-3108
Mailing Address - Country:US
Mailing Address - Phone:210-704-4100
Mailing Address - Fax:
Practice Address - Street 1:333 N SANTA ROSA
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-3108
Practice Address - Country:US
Practice Address - Phone:210-704-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-25
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA09323363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX345243503OtherCSHCN
TX345243502Medicaid