Provider Demographics
NPI:1063028298
Name:KULTAN, KANOKWAN
Entity Type:Individual
Prefix:
First Name:KANOKWAN
Middle Name:
Last Name:KULTAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15850 BABCOCK ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-3680
Mailing Address - Country:US
Mailing Address - Phone:858-344-8536
Mailing Address - Fax:
Practice Address - Street 1:15850 BABCOCK ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92127-3680
Practice Address - Country:US
Practice Address - Phone:858-344-8536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95015361363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care