Provider Demographics
NPI:1104006741
Name:LOVE, JUSTIN DAVID (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:DAVID
Last Name:LOVE
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 1:25865 BARTON RD, SUITE 101, BLDG D
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354
Mailing Address - Country:US
Mailing Address - Phone:909-558-2890
Mailing Address - Fax:
Practice Address - Street 1:25865 BARTON RD, SUITE 101, BLDG D
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354
Practice Address - Country:US
Practice Address - Phone:909-558-2890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-12
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18651363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical