Provider Demographics
NPI: | 1497023659 |
---|---|
Name: | CHRISTY, JUSTIN LUKE (PA-C) |
Entity Type: | Individual |
Prefix: | MR |
First Name: | JUSTIN |
Middle Name: | LUKE |
Last Name: | CHRISTY |
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: | 2465 EMERALD PLACE |
Mailing Address - Street 2: | |
Mailing Address - City: | GREENVILLE |
Mailing Address - State: | NC |
Mailing Address - Zip Code: | 27834 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 910-763-5182 |
Mailing Address - Fax: | 910-763-0291 |
Practice Address - Street 1: | 2465 EMERALD PLACE |
Practice Address - Street 2: | |
Practice Address - City: | GREENVILLE |
Practice Address - State: | NC |
Practice Address - Zip Code: | 27834 |
Practice Address - Country: | US |
Practice Address - Phone: | 252-758-2424 |
Practice Address - Fax: | 910-763-0291 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2011-12-02 |
Last Update Date: | 2023-01-25 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NC | 0010-03179 | 363AM0700X, 363A00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | |
No | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NC | 1497023659 | Medicaid | |
NC | 8101466 | Medicaid |