Provider Demographics
NPI:1295225506
Name:MAIN, JUSTIN LERAY (MSN, APRN, FNP-BC)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:LERAY
Last Name:MAIN
Suffix:
Gender:M
Credentials:MSN, APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1913 S JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48708-8742
Mailing Address - Country:US
Mailing Address - Phone:989-965-2168
Mailing Address - Fax:
Practice Address - Street 1:1913 S JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708-8742
Practice Address - Country:US
Practice Address - Phone:989-965-2168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-11
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704292433363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily