Provider Demographics
NPI:1841923117
Name:KUBY, JOANNA
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:
Last Name:KUBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4551 GLENCOE AVE STE 145
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6385
Mailing Address - Country:US
Mailing Address - Phone:310-426-8206
Mailing Address - Fax:
Practice Address - Street 1:4551 GLENCOE AVE STE 145
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6385
Practice Address - Country:US
Practice Address - Phone:310-426-8206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-05
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA63603363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical