Provider Demographics
NPI:1083626493
Name:DUBOIS, TONYA (PA-C)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:
Last Name:DUBOIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1879 EVENINGSIDE WAY NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-4794
Mailing Address - Country:US
Mailing Address - Phone:903-806-6536
Mailing Address - Fax:
Practice Address - Street 1:644 THORNTON RD
Practice Address - Street 2:
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122
Practice Address - Country:US
Practice Address - Phone:678-915-9887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04195363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11997OtherGEORGIA MEDICAL BOARD
TX8N7622OtherBCBS
TX8C8702Medicare ID - Type UnspecifiedRURAL
TX8C7621Medicare ID - Type UnspecifiedFORT WORTH