Provider Demographics
NPI:1497425904
Name:KUBE, MICAELA GRACE (PA)
Entity Type:Individual
Prefix:
First Name:MICAELA
Middle Name:GRACE
Last Name:KUBE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 QUEENS PLZ N
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-4020
Mailing Address - Country:US
Mailing Address - Phone:122-283-3000
Mailing Address - Fax:646-665-3604
Practice Address - Street 1:65 BROADWAY STE 1800
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10006-2549
Practice Address - Country:US
Practice Address - Phone:646-665-3634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1185508363A00000X
NJ25MP00629400363A00000X
NY027198363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty