Provider Demographics
NPI:1811672934
Name:KUKULKA, JOSIAH CALEB (PTA)
Entity type:Individual
Prefix:
First Name:JOSIAH
Middle Name:CALEB
Last Name:KUKULKA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151420 LUPINE RD
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-6635
Mailing Address - Country:US
Mailing Address - Phone:715-203-2699
Mailing Address - Fax:
Practice Address - Street 1:4810 BARBICAN AVE
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WI
Practice Address - Zip Code:54476-4186
Practice Address - Country:US
Practice Address - Phone:715-393-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-16
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant