Provider Demographics
NPI:1043229677
Name:KUBIC, LESLIE ANNE (PA (PHYSICIAN ASSIST)
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:ANNE
Last Name:KUBIC
Suffix:
Gender:F
Credentials:PA (PHYSICIAN ASSIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 CUMMINGS CTR STE 112W
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-6183
Mailing Address - Country:US
Mailing Address - Phone:978-927-8844
Mailing Address - Fax:
Practice Address - Street 1:900 CUMMINGS CTR
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-6198
Practice Address - Country:US
Practice Address - Phone:978-927-8841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1011363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP77279Medicare UPIN