Provider Demographics
NPI:1467469734
Name:KUBOTA, RICHARD KENJI (PA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:KENJI
Last Name:KUBOTA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1718 REDWOOD LN
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-1020
Mailing Address - Country:US
Mailing Address - Phone:916-734-1107
Mailing Address - Fax:916-734-6474
Practice Address - Street 1:4860 Y ST
Practice Address - Street 2:SUITE 0200
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2307
Practice Address - Country:US
Practice Address - Phone:916-734-1107
Practice Address - Fax:916-734-6474
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA12906363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant