Basic Information
| Provider Information | |||||||||
| NPI: | 1235128612 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STOUT | ||||||||
| FirstName: | BOBBY | ||||||||
| MiddleName: | GENE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2205 | ||||||||
| Address2: | |||||||||
| City: | LOGANVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300520050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6786140900 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 631 PROFESSIONAL DR STE 360 | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300463370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783122700 | ||||||||
| FaxNumber: | 6783122730 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2005 | ||||||||
| LastUpdateDate: | 03/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 003770 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 068027283B | 05 | GA | MEDICAID |