Provider Demographics
NPI:1093304669
Name:AJOSE, JUSTIN (PA-C)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:AJOSE
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 1:2004 ROCK SPRING RD.
Mailing Address - Street 2:
Mailing Address - City:FOREST HILL
Mailing Address - State:MD
Mailing Address - Zip Code:21050-2310
Mailing Address - Country:US
Mailing Address - Phone:444-640-4524
Mailing Address - Fax:443-567-5574
Practice Address - Street 1:1354 EASTERN BLVD
Practice Address - Street 2:
Practice Address - City:ESSEX
Practice Address - State:MD
Practice Address - Zip Code:21221-3423
Practice Address - Country:US
Practice Address - Phone:443-640-4524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-18
Last Update Date:2021-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1167981363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical