Provider Demographics
NPI:1972782514
Name:KUKHOTSKY, SERGEY D (PAC)
Entity Type:Individual
Prefix:
First Name:SERGEY
Middle Name:D
Last Name:KUKHOTSKY
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 1:1019 112TH ST SW
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98204
Mailing Address - Country:US
Mailing Address - Phone:425-551-6200
Mailing Address - Fax:425-551-6017
Practice Address - Street 1:1019 112TH ST SW
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98204
Practice Address - Country:US
Practice Address - Phone:425-551-6200
Practice Address - Fax:425-551-6017
Is Sole Proprietor?:No
Enumeration Date:2007-10-31
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10005315363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant