Provider Demographics
NPI:1912023953
Name:ROUTT, STEPHEN B (PA-C)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:B
Last Name:ROUTT
Suffix:
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 1:5080 SPECTRUM DRIVE
Mailing Address - Street 2:SUITE 1200 WEST TOWER
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001
Mailing Address - Country:US
Mailing Address - Phone:800-232-3550
Mailing Address - Fax:
Practice Address - Street 1:1368 SOUTHLAKE PROFESSIONAL PLACE
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260
Practice Address - Country:US
Practice Address - Phone:615-778-4066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000750363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511G700201Medicare PIN
GA511I970112Medicare UPIN
GA202I970846Medicare UPIN