Provider Demographics
NPI:1356870174
Name:JUBA, ALLISON MARIE HOMSTAD (DO)
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:MARIE HOMSTAD
Last Name:JUBA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:ALLISON
Other - Middle Name:MARIE
Other - Last Name:HOMSTAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:610 30TH AVE W
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-3426
Mailing Address - Country:US
Mailing Address - Phone:320-763-2540
Mailing Address - Fax:320-763-5749
Practice Address - Street 1:610 30TH AVE W
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-3426
Practice Address - Country:US
Practice Address - Phone:320-763-2540
Practice Address - Fax:320-763-7883
Is Sole Proprietor?:No
Enumeration Date:2017-06-06
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN64351390200000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program