Provider Demographics
NPI:1952625642
Name:LUBERDA, MARY B (CST)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:B
Last Name:LUBERDA
Suffix:
Gender:F
Credentials:CST
Other - Prefix:
Other - First Name:BOBBI
Other - Middle Name:
Other - Last Name:LUBERDA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CST
Mailing Address - Street 1:PO BOX 19070
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54307-9070
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:
Practice Address - Street 1:143 ACREVIEW DR
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-3655
Practice Address - Country:US
Practice Address - Phone:920-496-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-24
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
075288OtherCERTIFIED SURGICAL TECHNOLOGIST