Basic Information
| Provider Information | |||||||||
| NPI: | 1780602490 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KUBISTY | ||||||||
| FirstName: | CHERYL | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 830 NE IRELAND | ||||||||
| Address2: | |||||||||
| City: | OAK HARBOR | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606757678 | ||||||||
| FaxNumber: | 3602790614 | ||||||||
| Practice Location | |||||||||
| Address1: | 830 NE IRELAND | ||||||||
| Address2: | |||||||||
| City: | OAK HARBOR | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606757678 | ||||||||
| FaxNumber: | 3602790614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 09/19/2016 | ||||||||
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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 | 174400000X | MD00030606 | WA | Y | Other Service Providers | Specialist | 207R00000X | M-12093 | ID | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1108687 | 05 | WA | MEDICAID |