Basic Information
| Provider Information | |||||||||
| NPI: | 1073907713 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRUBER | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | ANN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1150 YOUNGS RD | ||||||||
| Address2: | STE 104 | ||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142218024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166367990 | ||||||||
| FaxNumber: | 7166367990 | ||||||||
| Practice Location | |||||||||
| Address1: | 640 ELLICOTT ST | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142031245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168931010 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2015 | ||||||||
| LastUpdateDate: | 01/09/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F339516-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.