Provider Demographics
NPI:1902143787
Name:WUBNEH, KATRINA (PA-C)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:WUBNEH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATRINA
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:3450 11TH CT STE 203
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-5012
Mailing Address - Country:US
Mailing Address - Phone:772-770-0323
Mailing Address - Fax:
Practice Address - Street 1:3450 11TH CT STE 203
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-5012
Practice Address - Country:US
Practice Address - Phone:772-770-0323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-14
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109028363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016555800Medicaid
FL016555800Medicaid