Provider Demographics
NPI:1730171588
Name:DUBLA, GREGORY MARK (RN,CRNA)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:MARK
Last Name:DUBLA
Suffix:
Gender:M
Credentials:RN,CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 EAST 3RD STREET
Mailing Address - Street 2:ESSENTIA HEALTH DULUTH CLINIC
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805
Mailing Address - Country:US
Mailing Address - Phone:218-783-8364
Mailing Address - Fax:
Practice Address - Street 1:400 EAST 3RD STREET
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805
Practice Address - Country:US
Practice Address - Phone:218-783-8364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI108993367500000X
MNR1005525367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered