Provider Demographics
NPI:1518070036
Name:TUBBS, RICHARD SHANE (PHD,PA-C)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:SHANE
Last Name:TUBBS
Suffix:
Gender:M
Credentials:PHD,PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 S ROBERTSON ST STE 1300
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70112-2807
Mailing Address - Country:US
Mailing Address - Phone:504-988-5565
Mailing Address - Fax:504-988-5793
Practice Address - Street 1:1415 TULANE AVE FL 5
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112
Practice Address - Country:US
Practice Address - Phone:504-988-5561
Practice Address - Fax:504-988-1731
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA053363A00000X
WAPA60600928363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051509068OtherBCBS OF AL
AL051509068Medicaid
AL970027041OtherRR MEDICARE
AL051509068Medicaid