Provider Demographics
NPI:1598232001
Name:KULICK, KRISTYN (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTYN
Middle Name:
Last Name:KULICK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7386 OAKSTONE DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48348-4763
Mailing Address - Country:US
Mailing Address - Phone:248-330-0765
Mailing Address - Fax:
Practice Address - Street 1:2820 CROOKS RD STE 100
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48309-3620
Practice Address - Country:US
Practice Address - Phone:586-977-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-01
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008759363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant