Provider Demographics
NPI:1942858709
Name:BOUBERT, JOSEPH JUNIOR
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:JUNIOR
Last Name:BOUBERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2135 S CONGRESS AVE STE 4A
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33406-7611
Mailing Address - Country:US
Mailing Address - Phone:561-965-6333
Mailing Address - Fax:866-678-3710
Practice Address - Street 1:2135 S CONGRESS AVE STE 4A
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33406-7611
Practice Address - Country:US
Practice Address - Phone:561-965-6333
Practice Address - Fax:866-678-3710
Is Sole Proprietor?:No
Enumeration Date:2019-08-26
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR312-P.A.363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner