Provider Demographics
NPI:1083168454
Name:STAFFORD, JUSTIN (PA-C)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:STAFFORD
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 1:3533 SOUTHERN BLVD
Mailing Address - Street 2:SUITE 2100
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-1264
Mailing Address - Country:US
Mailing Address - Phone:937-395-8556
Mailing Address - Fax:937-522-7873
Practice Address - Street 1:3535 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1221
Practice Address - Country:US
Practice Address - Phone:937-395-6020
Practice Address - Fax:937-522-7873
Is Sole Proprietor?:No
Enumeration Date:2016-08-15
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004770RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0181657Medicaid
OH0181657Medicaid