Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080A0000X | Adolescent Medicine | 266667-1 | NY |
NPI | 1306088190 |
---|---|
Provider Name | Khristina Kasuba |
First Address | Depew, NY 14043-4776 |
Second Address | Depew, NY 14043-4776 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/03/2009 |
Last Update Date | 25/01/2013 |