Healthcare Provider Details

I. General information

NPI: 1417629585
Provider Name (Legal Business Name): THOMAS DUBE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2021
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6721 FRESH POND RD
RIDGEWOOD NY
11385-4562
US

IV. Provider business mailing address

4300 MARKET PTE DR STE 100
BLOOMINGTON MN
55435-5435
US

V. Phone/Fax

Practice location:
  • Phone: 929-468-9920
  • Fax:
Mailing address:
  • Phone: 952-767-4574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number027508-01
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number15334
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: