Basic Information
| Provider Information | |||||||||
| NPI: | 1225676752 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRUBER | ||||||||
| FirstName: | MCKENNA | ||||||||
| MiddleName: | KATE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13460 N. 94TH DRIVE | ||||||||
| Address2: | STE J-1 | ||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853814246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238768816 | ||||||||
| FaxNumber: | 6232980168 | ||||||||
| Practice Location | |||||||||
| Address1: | 13460 N. 94TH DRIVE | ||||||||
| Address2: | STE J-1 | ||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853814246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238768816 | ||||||||
| FaxNumber: | 6232980168 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2019 | ||||||||
| LastUpdateDate: | 12/16/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/16/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 7506 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.