Basic Information
| Provider Information | |||||||||
| NPI: | 1326108242 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STUBER | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2429 | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986328486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605758275 | ||||||||
| FaxNumber: | 3605751948 | ||||||||
| Practice Location | |||||||||
| Address1: | 1044 11TH AVE | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986322506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605758275 | ||||||||
| FaxNumber: | 3605751948 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 09/16/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | MD0015256 | WA | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1143403 | 05 | WA | MEDICAID | 119838 | 01 | WA | LABOR INDUSTRIES | OTHER |