Provider Demographics
NPI:1801984489
Name:STUBBS, JOHN LLEWELLYN (AA-C)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:LLEWELLYN
Last Name:STUBBS
Suffix:
Gender:M
Credentials:AA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1472 HEDGEWOOD LN NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-4513
Mailing Address - Country:US
Mailing Address - Phone:770-419-5867
Mailing Address - Fax:
Practice Address - Street 1:531 ROSELANE ST NW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-6913
Practice Address - Country:US
Practice Address - Phone:770-794-0477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003175367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant