Provider Demographics
NPI:1558358762
Name:KUKUCK, TODD G (CRNA)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:G
Last Name:KUKUCK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 BRECKENRIDGE LN
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-2742
Mailing Address - Country:US
Mailing Address - Phone:502-458-7400
Mailing Address - Fax:502-458-7449
Practice Address - Street 1:3101 BRECKENRIDGE LN
Practice Address - Street 2:SUITE 1A
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-2742
Practice Address - Country:US
Practice Address - Phone:502-458-7400
Practice Address - Fax:502-458-7449
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1054875367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY2435210000OtherPASSPORT ADVANTAGE
430009072OtherRAILROAD MEDICARE
KY74383951Medicaid
KY1075148OtherPASSPORT
KY000000283592OtherBLUE SHIELD
KY2435210000OtherPASSPORT ADVANTAGE