Provider Demographics
NPI:1588601231
Name:KUBICKA, PATRICIA RIESS (MD)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:RIESS
Last Name:KUBICKA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:LYNN
Other - Last Name:RIESS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:290 MAIN ST NW
Mailing Address - Street 2:
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330-1270
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:290 MAIN ST NW
Practice Address - Street 2:
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-1270
Practice Address - Country:US
Practice Address - Phone:763-241-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47524208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNI29458Medicare UPIN