Provider Demographics
NPI:1104187657
Name:KUJACZNSKI, LAURA (PA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:KUJACZNSKI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 S KALAMAZOO MALL
Mailing Address - Street 2:SUITE 204
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-4832
Mailing Address - Country:US
Mailing Address - Phone:269-324-3390
Mailing Address - Fax:269-343-5640
Practice Address - Street 1:125 S KALAMAZOO MALL
Practice Address - Street 2:SUITE 204
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-4832
Practice Address - Country:US
Practice Address - Phone:269-324-3390
Practice Address - Fax:269-343-5640
Is Sole Proprietor?:No
Enumeration Date:2012-05-31
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM79650090Medicare PIN
MIP08090110Medicare UPIN
MIC96159137Medicare PIN