Provider Demographics
NPI:1235128612
Name:STOUT, BOBBY GENE JR (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BOBBY
Middle Name:GENE
Last Name:STOUT
Suffix:JR
Gender:M
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:PO BOX 2205
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-0050
Mailing Address - Country:US
Mailing Address - Phone:678-614-0900
Mailing Address - Fax:
Practice Address - Street 1:631 PROFESSIONAL DR STE 360
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3370
Practice Address - Country:US
Practice Address - Phone:678-312-2700
Practice Address - Fax:678-312-2730
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003770363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA068027283BMedicaid
GA97WCHRVMedicare ID - Type Unspecified
GA068027283BMedicaid
GA97WCFXJMedicare ID - Type Unspecified
GA511I970087Medicare PIN