Provider Demographics
NPI:1275581043
Name:CUCCUINI, ALICE (PA)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:CUCCUINI
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 1:600 COFFEE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4201
Mailing Address - Country:US
Mailing Address - Phone:209-524-1211
Mailing Address - Fax:
Practice Address - Street 1:801 E ST
Practice Address - Street 2:
Practice Address - City:PATTERSON
Practice Address - State:CA
Practice Address - Zip Code:95363-2670
Practice Address - Country:US
Practice Address - Phone:209-892-2081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA12665363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PA126650Medicaid
CA0PA126651Medicare PIN
CAR23462Medicare UPIN