Provider Demographics
NPI:1578768644
Name:STUBBS, JASON TRYGVE (DO)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:TRYGVE
Last Name:STUBBS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3654 N INVESTMENT DR # 120
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-5441
Mailing Address - Country:US
Mailing Address - Phone:216-904-6596
Mailing Address - Fax:
Practice Address - Street 1:3654 N INVESTMENT DR # 120
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-5441
Practice Address - Country:US
Practice Address - Phone:216-904-6596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02004173A207YS0123X
MI5101022863208200000X, 207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery