Healthcare Provider Details

I. General information

NPI: 1316561798
Provider Name (Legal Business Name): ALEXANDRA KUBERKA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2020
Last Update Date: 05/17/2021
Certification Date: 05/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1182 TROY SCHENECTADY RD STE 100
LATHAM NY
12110-1000
US

IV. Provider business mailing address

PO BOX 14890
ALBANY NY
12212-4890
US

V. Phone/Fax

Practice location:
  • Phone: 518-713-5400
  • Fax:
Mailing address:
  • Phone: 518-525-5634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number025200
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: