Provider Demographics
NPI:1841217403
Name:KUCZEK, WABANANG GAIASHKIBOS (MPH, PA-C)
Entity Type:Individual
Prefix:MRS
First Name:WABANANG
Middle Name:GAIASHKIBOS
Last Name:KUCZEK
Suffix:
Gender:F
Credentials:MPH, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 CLOUD MARCH E
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87506-2171
Mailing Address - Country:US
Mailing Address - Phone:505-989-1893
Mailing Address - Fax:
Practice Address - Street 1:1600 SAINT MICHAELS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7615
Practice Address - Country:US
Practice Address - Phone:505-473-6918
Practice Address - Fax:505-473-6467
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2003-0044363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical