Provider Demographics
NPI:1114512480
Name:TUBBS, KRYSTAL AULTMAN (PA-C)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:AULTMAN
Last Name:TUBBS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRYSTAL
Other - Middle Name:DAWN
Other - Last Name:AULTMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11324 LEXIE LN
Mailing Address - Street 2:
Mailing Address - City:BROOKWOOD
Mailing Address - State:AL
Mailing Address - Zip Code:35444-1077
Mailing Address - Country:US
Mailing Address - Phone:334-419-8051
Mailing Address - Fax:
Practice Address - Street 1:1774 MCFARLAND BLVD N
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35406-2136
Practice Address - Country:US
Practice Address - Phone:205-247-3030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-08
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AL1778363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program