Provider Demographics
NPI:1215408638
Name:SUTTON, JUSTIN DAVON (PERMIT TO CARRY GUN)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:DAVON
Last Name:SUTTON
Suffix:
Gender:M
Credentials:PERMIT TO CARRY GUN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 AUDREY LN APT 102
Mailing Address - Street 2:
Mailing Address - City:OXON HILL
Mailing Address - State:MD
Mailing Address - Zip Code:20745-4626
Mailing Address - Country:US
Mailing Address - Phone:202-487-1204
Mailing Address - Fax:
Practice Address - Street 1:640 AUDREY LN APT 102
Practice Address - Street 2:
Practice Address - City:OXON HILL
Practice Address - State:MD
Practice Address - Zip Code:20745-4626
Practice Address - Country:US
Practice Address - Phone:202-487-1204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-11
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCCPRMedicaid
VA99-500540OtherPERMIT TO CARRY A HANDGUN VA
DC2356696Medicaid
MD438-95732OtherPERMIT TO CARRY A HANDGUN
DCCPRMedicaid