Provider Demographics
NPI:1013907013
Name:KULP, EDWARD (PAC)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:KULP
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 1:106 BLANCA AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-2340
Mailing Address - Country:US
Mailing Address - Phone:719-589-8082
Mailing Address - Fax:719-587-6354
Practice Address - Street 1:2115 STUART AVE
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-2269
Practice Address - Country:US
Practice Address - Phone:719-589-8082
Practice Address - Fax:719-587-6354
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1090363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO65457820Medicaid
970027493OtherTRAVELERS MEDICARE
CO840706945074OtherROCKY MOUNTAIN HEALTH PLA
S83070Medicare UPIN
466368Medicare ID - Type Unspecified
COCOA103909Medicare PIN