Provider Demographics
NPI:1578759536
Name:JUSTIN, CHARLENE OLIVIA (PA-C)
Entity Type:Individual
Prefix:MS
First Name:CHARLENE
Middle Name:OLIVIA
Last Name:JUSTIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:CHARLENE
Other - Middle Name:OLIVIA
Other - Last Name:JUSTIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:800 HOWARD AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1369
Mailing Address - Country:US
Mailing Address - Phone:650-759-1426
Mailing Address - Fax:
Practice Address - Street 1:800 HOWARD AVE FL 1
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1369
Practice Address - Country:US
Practice Address - Phone:203-785-7411
Practice Address - Fax:203-785-4194
Is Sole Proprietor?:No
Enumeration Date:2007-09-23
Last Update Date:2019-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51298363A00000X
NC0010-06058363A00000X, 363A00000X
CT3263363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MNENROLLEDMedicaid