Provider Demographics
NPI:1164414223
Name:KUBACAK, CAROLYN (CRNA)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:
Last Name:KUBACAK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:HEREFORD
Mailing Address - State:TX
Mailing Address - Zip Code:79045-5727
Mailing Address - Country:US
Mailing Address - Phone:806-364-2141
Mailing Address - Fax:806-349-9377
Practice Address - Street 1:801 E 3RD ST
Practice Address - Street 2:
Practice Address - City:HEREFORD
Practice Address - State:TX
Practice Address - Zip Code:79045-5727
Practice Address - Country:US
Practice Address - Phone:806-364-2141
Practice Address - Fax:806-349-9377
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX028421367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered