Provider Demographics
NPI:1467950071
Name:CANTRELL, JUSTIN A (PA-C)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:A
Last Name:CANTRELL
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 1:4160 LITTLE YORK RD
Mailing Address - Street 2:STE 10
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414-5803
Mailing Address - Country:US
Mailing Address - Phone:937-415-9100
Mailing Address - Fax:
Practice Address - Street 1:4160 LITTLE YORK RD STE 10
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414-5803
Practice Address - Country:US
Practice Address - Phone:937-415-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-29
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.005432363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0267433Medicaid