Provider Demographics
NPI:1982107256
Name:KULLERKUPP, PEACE (PARAMEDIC)
Entity type:Individual
Prefix:
First Name:PEACE
Middle Name:
Last Name:KULLERKUPP
Suffix:
Gender:M
Credentials:PARAMEDIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 BANKO DR
Mailing Address - Street 2:
Mailing Address - City:DEPEW
Mailing Address - State:NY
Mailing Address - Zip Code:14043-1206
Mailing Address - Country:US
Mailing Address - Phone:716-240-8523
Mailing Address - Fax:
Practice Address - Street 1:152 BANKO DR
Practice Address - Street 2:
Practice Address - City:DEPEW
Practice Address - State:NY
Practice Address - Zip Code:14043-1206
Practice Address - Country:US
Practice Address - Phone:716-240-8523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY129508146L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY74-3156453OtherFEDERAL NUMBER