Provider Demographics
NPI:1245576180
Name:STUART, DUSTIN TY (PA-C)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:TY
Last Name:STUART
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 1:3024 BUSINESS PARK CIR
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-3132
Mailing Address - Country:US
Mailing Address - Phone:615-239-2018
Mailing Address - Fax:
Practice Address - Street 1:776 WEATHERLY DR STE B
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-8922
Practice Address - Country:US
Practice Address - Phone:615-941-8501
Practice Address - Fax:615-941-8102
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-21
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
TN3834363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant