Provider Demographics
NPI:1952837767
Name:KANYUCK, ANNA MARIE
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:MARIE
Last Name:KANYUCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:MARIE
Other - Last Name:VERSAGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:605 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-2620
Mailing Address - Country:US
Mailing Address - Phone:610-565-8600
Mailing Address - Fax:610-891-9238
Practice Address - Street 1:605 W STATE ST
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-2620
Practice Address - Country:US
Practice Address - Phone:610-565-8600
Practice Address - Fax:610-891-9238
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS019761207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine