Provider Demographics
NPI:1417266347
Name:HARTUNG, JUSTIN LEE (PA-C, MMS)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:LEE
Last Name:HARTUNG
Suffix:
Gender:M
Credentials:PA-C, MMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13406 AIRLINE HWY
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70817-5917
Mailing Address - Country:US
Mailing Address - Phone:225-753-7233
Mailing Address - Fax:225-753-5188
Practice Address - Street 1:13406 AIRLINE HWY
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70817-5917
Practice Address - Country:US
Practice Address - Phone:225-753-7233
Practice Address - Fax:225-753-5188
Is Sole Proprietor?:No
Enumeration Date:2010-09-27
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200334.RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAPA.200334.RXOtherLOUISIANA LICENSE NUMBER