Provider Demographics
NPI:1154305076
Name:BUBACK, DEBRA (RN, MSN, ANP)
Entity Type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:
Last Name:BUBACK
Suffix:
Gender:F
Credentials:RN, MSN, ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12855 N 40 DR
Mailing Address - Street 2:SUITE 375
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8635
Mailing Address - Country:US
Mailing Address - Phone:314-567-6071
Mailing Address - Fax:314-567-7961
Practice Address - Street 1:12855 N 40 DR
Practice Address - Street 2:SUITE 375
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8635
Practice Address - Country:US
Practice Address - Phone:314-567-6071
Practice Address - Fax:314-567-7961
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO063206364SM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SM0705XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO154193OtherBLUE CROSS BLUE SHIELD
MOP90315Medicare UPIN