Provider Demographics
NPI:1578712345
Name:KUBACKI, PATRICIA E
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:E
Last Name:KUBACKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-6497
Mailing Address - Country:US
Mailing Address - Phone:715-842-9882
Mailing Address - Fax:715-858-0659
Practice Address - Street 1:330 GRAND AVE
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-6497
Practice Address - Country:US
Practice Address - Phone:715-842-9882
Practice Address - Fax:715-858-0659
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-16
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI806-060237700000X
MI3501003011237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3501003011OtherHEARING AID SALESPERSON LICENSE
WI806 060OtherHEARING INSTRUMENT SPECIALIST LIC #