Provider Demographics
NPI:1407184724
Name:KUTZENBERGER, DANIELLE NICOLE (PA)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:NICOLE
Last Name:KUTZENBERGER
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 1:2800 S TEXAS AVE
Mailing Address - Street 2:STE 202
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-5361
Mailing Address - Country:US
Mailing Address - Phone:979-774-2053
Mailing Address - Fax:979-776-5914
Practice Address - Street 1:3526 LONGMIRE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-6472
Practice Address - Country:US
Practice Address - Phone:979-696-3344
Practice Address - Fax:979-696-5944
Is Sole Proprietor?:No
Enumeration Date:2009-11-24
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06547363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX374198YSF3Medicare PIN
TX279583YKWUMedicare PIN
TX296901603Medicaid
TX296901604Medicaid
TX296901605Medicaid
TX8358NDOtherBLUE CROSS BLUE SHIELD
TX279583YMVQMedicare PIN
TX279583YNPNMedicare PIN
TX1407184724OtherBLUE CROSS BLUE SHIELD
TX279583YQ64Medicare PIN