Provider Demographics
NPI:1245777929
Name:WASDIN, JUSTIN D (PA-C)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:D
Last Name:WASDIN
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:PO BOX 417
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-0417
Mailing Address - Country:US
Mailing Address - Phone:772-223-2832
Mailing Address - Fax:772-223-5646
Practice Address - Street 1:10080 SW INNOVATION WAY STE 102
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-2129
Practice Address - Country:US
Practice Address - Phone:772-344-3811
Practice Address - Fax:772-283-4919
Is Sole Proprietor?:No
Enumeration Date:2017-01-19
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110163363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019931500Medicaid
FLJ2ZXGOtherFLORIDA BLUE
FLJ2ZXGOtherFLORIDA BLUE