Healthcare Provider Details

I. General information

NPI: 1457864993
Provider Name (Legal Business Name): NICOLE BUBES PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2017
Last Update Date: 09/27/2022
Certification Date: 09/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 N SAINT CLAIR ST STE 21-100
CHICAGO IL
60611-5970
US

IV. Provider business mailing address

675 N SAINT CLAIR ST STE 21-100
CHICAGO IL
60611-5970
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-0990
  • Fax: 312-695-1106
Mailing address:
  • Phone: 312-695-0990
  • Fax: 312-695-1106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085007652
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: