Provider Demographics
NPI:1861743569
Name:RUBIO, PROMISE GOLDYN (PA-C)
Entity type:Individual
Prefix:
First Name:PROMISE
Middle Name:GOLDYN
Last Name:RUBIO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:PROMISE
Other - Middle Name:GOLDYN
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 936535
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-6535
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2000 GLEN ECHO RD STE 111
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37215-2857
Practice Address - Country:US
Practice Address - Phone:615-657-4805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-21
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2012-0033363A00000X, 363AS0400X
TN5036363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMP01322421OtherMEDICARE - RAILROAD
NM01931288Medicaid
NMP01322421OtherMEDICARE - RAILROAD