Basic Information
| Provider Information | |||||||||
| NPI: | 1275645541 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SKARDA | ||||||||
| FirstName: | VICKI | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KUBESH | ||||||||
| OtherFirstName: | VICKI | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 204 S ADAMS ST | ||||||||
| Address2: | |||||||||
| City: | SAINT CROIX FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540249449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154833221 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 204 S ADAMS ST | ||||||||
| Address2: | |||||||||
| City: | SAINT CROIX FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540249449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154833221 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 02/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 43271 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 072J3KU | 01 | MN | BLUE CROSS MN FACILITY | OTHER | 080176515 | 01 | RAILROAD | OTHER | 072J4KU | 01 | MN | BLUE CROSS MN PRO FEE | OTHER | 0107134 | 01 | MEDICA | OTHER | 43494800 | 05 | WI | MEDICAID | HP33862 | 01 | HEALTHPARTNERS | OTHER | NA9031028480 | 01 | PREFERREDONE | OTHER | 444251200 | 05 | MN | MEDICAID |