Basic Information
| Provider Information | |||||||||
| NPI: | 1700997665 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DUBOSE | ||||||||
| FirstName: | JOSHUA | ||||||||
| MiddleName: | BLAKE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4015 INTERSTATE 45 N | ||||||||
| Address2: | |||||||||
| City: | CONROE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773044901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9367566631 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4015 INTERSTATE 45 N | ||||||||
| Address2: | |||||||||
| City: | CONROE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773044901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9367566631 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 03/09/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA04882 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 188072603 | 05 | TX | MEDICAID |