Basic Information
Provider Information | |||||||||
NPI: | 1174693931 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STUBBLEFIELD | ||||||||
FirstName: | JON | ||||||||
MiddleName: | ERIC | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.A. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 192 LINDQUIST RD | ||||||||
Address2: | BUILDING 412 | ||||||||
City: | FORT STEWART | ||||||||
State: | GA | ||||||||
PostalCode: | 31314 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9124355457 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1110 W PEACHTREE ST NW STE 940 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303093609 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7702926500 | ||||||||
FaxNumber: | 7702926535 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/09/2006 | ||||||||
LastUpdateDate: | 12/20/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 009452-1 | NY | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 005200 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.