Provider Demographics
NPI:1538562103
Name:RODGERS, LAUREN NICOLE-KUBECK (PA-C)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:NICOLE-KUBECK
Last Name:RODGERS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7365 CARNELIAN ST STE 137
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-1100
Mailing Address - Country:US
Mailing Address - Phone:909-948-8888
Mailing Address - Fax:
Practice Address - Street 1:7365 CARNELIAN ST STE 137
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-1100
Practice Address - Country:US
Practice Address - Phone:909-948-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-26
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA51922363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant