Provider Demographics
NPI:1184026155
Name:LOVICH, JUSTIN EDWARD (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:EDWARD
Last Name:LOVICH
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 1:2439 E MINNEZONA AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4925
Mailing Address - Country:US
Mailing Address - Phone:928-607-4143
Mailing Address - Fax:
Practice Address - Street 1:2439 E MINNEZONA AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-4925
Practice Address - Country:US
Practice Address - Phone:928-607-4143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-22
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5810363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant