Provider Demographics
NPI:1538576491
Name:KUBIAK, VERNON ROBERT (APRN, CNS, CNP)
Entity type:Individual
Prefix:DR
First Name:VERNON
Middle Name:ROBERT
Last Name:KUBIAK
Suffix:
Gender:M
Credentials:APRN, CNS, CNP
Other - Prefix:DR
Other - First Name:VERNON
Other - Middle Name:ROBERT
Other - Last Name:KUBIAK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DNP
Mailing Address - Street 1:1070 HILINE RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2947
Mailing Address - Country:US
Mailing Address - Phone:208-478-9081
Mailing Address - Fax:208-478-4999
Practice Address - Street 1:1070 HILINE RD
Practice Address - Street 2:SUITE 210
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2947
Practice Address - Country:US
Practice Address - Phone:208-478-9081
Practice Address - Fax:208-478-4999
Is Sole Proprietor?:No
Enumeration Date:2014-07-11
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCNS-74A364SA2200X
ID54586363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health