Provider Demographics
NPI:1689975138
Name:KUKICH, CHERYL L (PA)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:L
Last Name:KUKICH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 ALLEN BRADLEY DR
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44124-6131
Mailing Address - Country:US
Mailing Address - Phone:440-459-5000
Mailing Address - Fax:877-712-6578
Practice Address - Street 1:300 ALLEN BRADLEY DR
Practice Address - Street 2:
Practice Address - City:MAYFIELD HTS
Practice Address - State:OH
Practice Address - Zip Code:44124-6131
Practice Address - Country:US
Practice Address - Phone:440-459-5000
Practice Address - Fax:877-712-6578
Is Sole Proprietor?:No
Enumeration Date:2010-11-15
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005909363AM0700X
IL085003953363AM0700X
OH50.004044RX363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical