Provider Demographics
NPI:1245619469
Name:HUBBARD, WILLIAM BLAKE (PA)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:BLAKE
Last Name:HUBBARD
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 1:100 RICE MINE ROAD LOOP STE 206
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35406-2418
Mailing Address - Country:US
Mailing Address - Phone:205-339-0171
Mailing Address - Fax:
Practice Address - Street 1:100 RICE MINE ROAD LOOP STE 206
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35406-2418
Practice Address - Country:US
Practice Address - Phone:205-339-0171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA.1054363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant