Provider Demographics
NPI:1821049198
Name:KANUCKEL, ROBERT B (PAC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:B
Last Name:KANUCKEL
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:937-619-4231
Practice Address - Street 1:7709 HOKE RD
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45315-9725
Practice Address - Country:US
Practice Address - Phone:937-836-4000
Practice Address - Fax:937-540-1090
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50000110363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00150614OtherRR MEDICARE FAIFIELD
P25125Medicare UPIN
KAPA22761Medicare PIN
OHPA35761Medicare PIN