Healthcare Provider Details

I. General information

NPI: 1538576491
Provider Name (Legal Business Name): VERNON ROBERT KUBIAK APRN, CNS, CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: VERNON ROBERT KUBIAK DNP

II. Dates (important events)

Enumeration Date: 07/11/2014
Last Update Date: 03/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1070 HILINE RD SUITE 210
POCATELLO ID
83201-2947
US

IV. Provider business mailing address

1070 HILINE RD SUITE 210
POCATELLO ID
83201-2947
US

V. Phone/Fax

Practice location:
  • Phone: 208-478-9081
  • Fax: 208-478-4999
Mailing address:
  • Phone: 208-478-9081
  • Fax: 208-478-4999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License NumberCNS-74A
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number54586
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: