Provider Demographics
NPI:1811312523
Name:KUKLA, ANDREW (MED, AT,C)
Entity type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:
Last Name:KUKLA
Suffix:
Gender:M
Credentials:MED, AT,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 MAIN ST
Mailing Address - Street 2:KENNEDY HOUSE
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08648-1600
Mailing Address - Country:US
Mailing Address - Phone:814-504-2037
Mailing Address - Fax:
Practice Address - Street 1:2500 MAIN ST
Practice Address - Street 2:KENNEDY HOUSE
Practice Address - City:LAWRENCEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08648-1600
Practice Address - Country:US
Practice Address - Phone:814-504-2037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-04
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT001526002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer