Provider Demographics
NPI:1033142930
Name:STULTZ, ROBERT ALAN (PA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:ALAN
Last Name:STULTZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 766
Mailing Address - Street 2:118 HOWARD ST.
Mailing Address - City:ROSSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30741-0766
Mailing Address - Country:US
Mailing Address - Phone:706-861-5539
Mailing Address - Fax:423-778-3157
Practice Address - Street 1:118 HOWARD ST
Practice Address - Street 2:
Practice Address - City:ROSSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30741-1314
Practice Address - Country:US
Practice Address - Phone:706-861-5539
Practice Address - Fax:706-861-5569
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN888363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP28358Medicare UPIN