Provider Demographics
NPI:1821302340
Name:RUBIO, NICOLE DANIELL (CRNA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:DANIELL
Last Name:RUBIO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0096
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:207 W. LEGION ROAD
Practice Address - Street 2:
Practice Address - City:BRAWLEY
Practice Address - State:CA
Practice Address - Zip Code:92227-7780
Practice Address - Country:US
Practice Address - Phone:760-351-3288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-27
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY599784-1163W00000X
CANA3980367500000X, 367500000X
CA087064367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB230195Medicare PIN
CAP01535108Medicare PIN