Provider Demographics
NPI:1780550624
Name:KUBKO, ALLEN R (FNP-C)
Entity type:Individual
Prefix:
First Name:ALLEN
Middle Name:R
Last Name:KUBKO
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 SANTA MONICA BLVD STE 424E
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2151
Mailing Address - Country:US
Mailing Address - Phone:310-590-7020
Mailing Address - Fax:310-310-2724
Practice Address - Street 1:2021 SANTA MONICA BLVD STE 424E
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2151
Practice Address - Country:US
Practice Address - Phone:310-590-7020
Practice Address - Fax:310-310-2724
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-16
Last Update Date:2025-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95032650363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty