Provider Demographics
NPI:1215331327
Name:BUBB, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BUBB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 ROUTE 59
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SUFFERN
Mailing Address - State:NY
Mailing Address - Zip Code:10901-4927
Mailing Address - Country:US
Mailing Address - Phone:845-357-5775
Mailing Address - Fax:845-357-5777
Practice Address - Street 1:68 HARRIS BUSHVILLE RD
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:NY
Practice Address - Zip Code:12701-3027
Practice Address - Country:US
Practice Address - Phone:845-794-3300
Practice Address - Fax:845-357-5777
Is Sole Proprietor?:No
Enumeration Date:2014-10-17
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY692806163W00000X, 367500000X
PA654959163W00000X
NJ26NR16012600163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse