Provider Demographics
NPI:1326654633
Name:GUGUMUCK, KORTNEY ROSE (PA-C)
Entity type:Individual
Prefix:
First Name:KORTNEY
Middle Name:ROSE
Last Name:GUGUMUCK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KORTNEY
Other - Middle Name:ROSE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4104 STATE HIGHWAY 30
Mailing Address - Street 2:
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010-6202
Mailing Address - Country:US
Mailing Address - Phone:609-217-5649
Mailing Address - Fax:
Practice Address - Street 1:11835 RT 9W
Practice Address - Street 2:
Practice Address - City:WEST COXSACKIE
Practice Address - State:NY
Practice Address - Zip Code:12192-3605
Practice Address - Country:US
Practice Address - Phone:518-264-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-22
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025618363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty