Provider Demographics
NPI:1104378660
Name:PALUMBO, KURT DANIEL (PA)
Entity Type:Individual
Prefix:
First Name:KURT
Middle Name:DANIEL
Last Name:PALUMBO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 SPRUCE ST
Mailing Address - Street 2:GATES 5023
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4026
Mailing Address - Country:US
Mailing Address - Phone:215-614-0837
Mailing Address - Fax:
Practice Address - Street 1:3400 SPRUCE ST # 5023
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4238
Practice Address - Country:US
Practice Address - Phone:215-614-0837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020180363AM0700X
PAMA058993363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400345478-GRPBA0017Medicare PIN
NYJ400345475-GRP70008AMedicare PIN