MEDICARE: LISA TUBBS PAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant		OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619211307
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA TUBBS PAC

Provider Business Mailing Address
First Line	:	5450 FRANTZ RD STE 360
Second Line	:
City	:	DUBLIN
State	:	OH
Zip	:	43016-4141
Country	:	US
Telephone Number	:	419-520-2495
Fax Number	:

Provider Business Practice Location Address
First Line	:	2014 BALTIMORE REYNOLDSBURG RD
Second Line	:
City	:	REYNOLDSBURG
State	:	OH
Zip	:	43068-3261
Country	:	US
Telephone Number	:	614-522-6900
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/19/2012
Last Update Date	:	11/07/2019

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