Provider Demographics
NPI:1578313037
Name:ROBERTSON, JUSTIN ASHLEY
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ASHLEY
Last Name:ROBERTSON
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 1:1011 ROYAL OAK DR
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-9148
Mailing Address - Country:US
Mailing Address - Phone:502-507-8011
Mailing Address - Fax:
Practice Address - Street 1:1011 ROYAL OAK DR
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-9148
Practice Address - Country:US
Practice Address - Phone:502-507-8011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-26
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4015738363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily