Provider Demographics
NPI:1316413651
Name:TITUS, JUSTIN (PA)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:TITUS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4222 KETCHAM ST APT 6A
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-2367
Mailing Address - Country:US
Mailing Address - Phone:516-581-9947
Mailing Address - Fax:
Practice Address - Street 1:9425 60TH AVE
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-5069
Practice Address - Country:US
Practice Address - Phone:718-760-0797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-14
Last Update Date:2018-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021610363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant