Provider Demographics
NPI:1144382763
Name:KUKURUDA, JULIE ANN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:ANN
Last Name:KUKURUDA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:ANN
Other - Last Name:THAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1845
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28687-1845
Mailing Address - Country:US
Mailing Address - Phone:704-528-9903
Mailing Address - Fax:704-528-4192
Practice Address - Street 1:154 S MAIN ST
Practice Address - Street 2:
Practice Address - City:TROUTMAN
Practice Address - State:NC
Practice Address - Zip Code:28166-0200
Practice Address - Country:US
Practice Address - Phone:704-528-9903
Practice Address - Fax:704-528-4192
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001002803363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601001798OtherPA LICENSE
MI1017641OtherPA-CERTIFICATION