Provider Demographics
NPI:1952811283
Name:KABUSHINSKAYA, MARIA (PA-C)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:KABUSHINSKAYA
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 1:15051 S TAMIAMI TRL STE 203
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-5182
Mailing Address - Country:US
Mailing Address - Phone:239-437-8810
Mailing Address - Fax:239-437-8875
Practice Address - Street 1:7331 GLADIOLUS DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-5101
Practice Address - Country:US
Practice Address - Phone:239-437-8810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-30
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110675363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant