Provider Demographics
NPI:1265839013
Name:LUBER, KAYLAN MARIE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KAYLAN
Middle Name:MARIE
Last Name:LUBER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KAYLAN
Other - Middle Name:MARIE
Other - Last Name:BRAKORA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:201 S 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85003-2138
Mailing Address - Country:US
Mailing Address - Phone:602-506-2906
Mailing Address - Fax:
Practice Address - Street 1:201 S 4TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85003-2138
Practice Address - Country:US
Practice Address - Phone:602-506-2906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-21
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5870363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant