Healthcare Provider Details

I. General information

NPI: 1235379256
Provider Name (Legal Business Name): WADE DANIEL KUBAT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2009
Last Update Date: 01/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 E 2ND ST
DULUTH MN
55805-2200
US

IV. Provider business mailing address

1012 E 2ND ST
DULUTH MN
55805-2200
US

V. Phone/Fax

Practice location:
  • Phone: 218-249-7910
  • Fax: 218-249-7999
Mailing address:
  • Phone: 218-249-7910
  • Fax: 218-249-7999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number51974
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: