Provider Demographics
NPI:1396743050
Name:DUBA, JACQUELINE ANN (PA-C)
Entity type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:ANN
Last Name:DUBA
Suffix:
Gender:F
Credentials:PA-C
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 525
Mailing Address - Street 2:
Mailing Address - City:LEADVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80461-0525
Mailing Address - Country:US
Mailing Address - Phone:719-838-0655
Mailing Address - Fax:
Practice Address - Street 1:360 PEAK ONE DR STE 100
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:CO
Practice Address - Zip Code:80443-5948
Practice Address - Country:US
Practice Address - Phone:970-668-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0000930363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO40820025Medicaid
Q43174Medicare UPIN