Provider Demographics
NPI:1245770783
Name:AIVES, JUSTIN STEPHEN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:STEPHEN
Last Name:AIVES
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 1:500 E 77TH ST
Mailing Address - Street 2:1111
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10162-0025
Mailing Address - Country:US
Mailing Address - Phone:917-935-1149
Mailing Address - Fax:
Practice Address - Street 1:535 E 70TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4823
Practice Address - Country:US
Practice Address - Phone:212-606-1730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-02
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020558363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant