Provider Demographics
NPI:1003558024
Name:VEGA, JUSTINA LI (PA-C)
Entity Type:Individual
Prefix:
First Name:JUSTINA
Middle Name:LI
Last Name:VEGA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:748 OLD NORCROSS RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-3394
Mailing Address - Country:US
Mailing Address - Phone:770-339-1500
Mailing Address - Fax:770-339-3528
Practice Address - Street 1:655 JESSE JEWELL PKWY SE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3854
Practice Address - Country:US
Practice Address - Phone:770-533-7288
Practice Address - Fax:770-534-9800
Is Sole Proprietor?:No
Enumeration Date:2022-04-11
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA11301363A00000X, 363AM0700X, 363AS0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program