Basic Information
| Provider Information | |||||||||
| NPI: | 1124597521 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DUBECK | ||||||||
| FirstName: | TINA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 708760 | ||||||||
| Address2: | |||||||||
| City: | SANDY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840708760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013529500 | ||||||||
| FaxNumber: | 8013527976 | ||||||||
| Practice Location | |||||||||
| Address1: | 462 GRIDER ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142153021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7169616995 | ||||||||
| FaxNumber: | 7168985193 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2018 | ||||||||
| LastUpdateDate: | 11/15/2018 | ||||||||
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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 | 363L00000X | 657297 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.