Provider Demographics
NPI:1073907713
Name:GRUBER, KIMBERLY ANN
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:GRUBER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 YOUNGS RD
Mailing Address - Street 2:STE 104
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-8024
Mailing Address - Country:US
Mailing Address - Phone:716-636-7990
Mailing Address - Fax:716-636-7990
Practice Address - Street 1:640 ELLICOTT ST
Practice Address - Street 2:SUITE 105
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1245
Practice Address - Country:US
Practice Address - Phone:716-893-1010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-19
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF339516-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily