Provider Demographics
NPI:1386241867
Name:KOCIUBUK, ANDREW (APNP)
Entity type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:
Last Name:KOCIUBUK
Suffix:
Gender:M
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HIGH SERVICE AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-5113
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 HIGH SERVICE AVE
Practice Address - Street 2:
Practice Address - City:NORTH PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-5113
Practice Address - Country:US
Practice Address - Phone:401-456-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-07
Last Update Date:2025-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11039-33363LP0808X
OHRN.466178163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHRN.466178OtherREGISTERED NURSE