Provider Demographics
NPI:1376001438
Name:METHENY, JUSTIN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:METHENY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 DANNYS WAY
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-4752
Mailing Address - Country:US
Mailing Address - Phone:860-966-5631
Mailing Address - Fax:
Practice Address - Street 1:5 ALUMNI DR
Practice Address - Street 2:
Practice Address - City:EXETER
Practice Address - State:NH
Practice Address - Zip Code:03833-2128
Practice Address - Country:US
Practice Address - Phone:603-778-7311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-07
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH081640-23367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered