Provider Demographics
NPI:1700353729
Name:NACKOUD, KINDAH (PA-C)
Entity Type:Individual
Prefix:
First Name:KINDAH
Middle Name:
Last Name:NACKOUD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 963
Mailing Address - Street 2:
Mailing Address - City:SUNSET BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90742-0963
Mailing Address - Country:US
Mailing Address - Phone:818-421-3650
Mailing Address - Fax:
Practice Address - Street 1:16782 BAYVIEW DR
Practice Address - Street 2:
Practice Address - City:SUNSET BEACH
Practice Address - State:CA
Practice Address - Zip Code:90742
Practice Address - Country:US
Practice Address - Phone:818-421-3650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-29
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA56174363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant