Provider Demographics
NPI:1548823040
Name:KUBOTA, EVAN Y
Entity type:Individual
Prefix:DR
First Name:EVAN
Middle Name:Y
Last Name:KUBOTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 DILLON LN
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-9109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9080 BROOKS RD S
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CA
Practice Address - Zip Code:95492-7811
Practice Address - Country:US
Practice Address - Phone:707-837-2002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-19
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA80382183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist