Provider Demographics
NPI:1801438536
Name:RUBERG, PAUL
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:RUBERG
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 1:3930 PENDER DR STE 120
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-0986
Mailing Address - Country:US
Mailing Address - Phone:703-865-8686
Mailing Address - Fax:
Practice Address - Street 1:3930 PENDER DR STE 120
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-0986
Practice Address - Country:US
Practice Address - Phone:703-865-8686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-15
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110007711363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant