Provider Demographics
NPI:1609887694
Name:CUJDIK-KRIEGER, KATHRYN A (PA)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:A
Last Name:CUJDIK-KRIEGER
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:PO BOX 500
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:VA
Mailing Address - Zip Code:20116-0500
Mailing Address - Country:US
Mailing Address - Phone:301-203-2250
Mailing Address - Fax:
Practice Address - Street 1:11711 LIVINGSTON RD
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-5151
Practice Address - Country:US
Practice Address - Phone:301-203-2250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VI0110001216363A00000X
MD0110001216207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
S34295Medicare UPIN
VA007018E14Medicare ID - Type Unspecified