Basic Information
| Provider Information | |||||||||
| NPI: | 1073656732 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CUBIN | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | WARD | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 301 | ||||||||
| Address2: | |||||||||
| City: | ALPHARETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300090301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4705145538 | ||||||||
| FaxNumber: | 4705145561 | ||||||||
| Practice Location | |||||||||
| Address1: | 1265 HIGHWAY 54 W STE 103 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302144537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4705145538 | ||||||||
| FaxNumber: | 4705145561 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 01/26/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 863812372 | 01 | GA | N/A | OTHER |