Healthcare Provider Details

I. General information

NPI: 1215331327
Provider Name (Legal Business Name): JOHN BUBB
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2014
Last Update Date: 10/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

68 HARRIS BUSHVILLE RD
MONTICELLO NY
12701-3027
US

IV. Provider business mailing address

100 ROUTE 59 SUITE 105
SUFFERN NY
10901-4927
US

V. Phone/Fax

Practice location:
  • Phone: 845-794-3300
  • Fax: 845-357-5777
Mailing address:
  • Phone: 845-357-5775
  • Fax: 845-357-5777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number692806
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number654959
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NR16012600
License Number StateNJ
# 4
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number692806
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: