Provider Demographics
NPI:1669898565
Name:KURNIAWATI, RUTH (PA-C)
Entity type:Individual
Prefix:
First Name:RUTH
Middle Name:
Last Name:KURNIAWATI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3640 MAIN ST 103
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01107-1139
Mailing Address - Country:US
Mailing Address - Phone:413-785-5321
Mailing Address - Fax:413-731-7130
Practice Address - Street 1:50 WASON AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1132
Practice Address - Country:US
Practice Address - Phone:413-794-2222
Practice Address - Fax:413-794-1666
Is Sole Proprietor?:No
Enumeration Date:2014-03-16
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MAPA4974363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant