Provider Demographics
NPI:1689702292
Name:LUBAK, KRISTY DYANN (PA)
Entity Type:Individual
Prefix:MRS
First Name:KRISTY
Middle Name:DYANN
Last Name:LUBAK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KRISTY
Other - Middle Name:
Other - Last Name:HEYWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1534 VICTORY BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314
Mailing Address - Country:US
Mailing Address - Phone:718-667-3577
Mailing Address - Fax:718-667-3043
Practice Address - Street 1:1534 VICTORY BOULEVARD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314
Practice Address - Country:US
Practice Address - Phone:718-667-3577
Practice Address - Fax:718-667-3043
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006234363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical