Provider Demographics
NPI:1447417944
Name:BUBACK, JOYCE A
Entity Type:Individual
Prefix:
First Name:JOYCE
Middle Name:A
Last Name:BUBACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JOYCE
Other - Middle Name:B
Other - Last Name:FRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1001 CRAIG RD
Mailing Address - Street 2:SUITE 174
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-5277
Mailing Address - Country:US
Mailing Address - Phone:314-569-2688
Mailing Address - Fax:314-569-0409
Practice Address - Street 1:615 S NEW BALLAS RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8221
Practice Address - Country:US
Practice Address - Phone:314-569-2688
Practice Address - Fax:314-569-0409
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO066226367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered