Provider Demographics
NPI:1093277477
Name:LE, JUSTINE M (PA-C)
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:M
Last Name:LE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:2001 SANTA MONICA BLVD STE 1250W
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2217
Mailing Address - Country:US
Mailing Address - Phone:310-998-0040
Mailing Address - Fax:
Practice Address - Street 1:2001 SANTA MONICA BLVD STE 1250W
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2217
Practice Address - Country:US
Practice Address - Phone:310-998-0040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-03
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty