Provider Demographics
NPI:1922047885
Name:KUCERA, MARY LAEL (PA)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:LAEL
Last Name:KUCERA
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 1:508 MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-2808
Mailing Address - Country:US
Mailing Address - Phone:936-760-8543
Mailing Address - Fax:936-521-7389
Practice Address - Street 1:508 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-2808
Practice Address - Country:US
Practice Address - Phone:936-760-8543
Practice Address - Fax:936-521-7389
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00273363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXS25974Medicare UPIN
TX80N743Medicare PIN