Provider Demographics
NPI:1578800819
Name:GARRISON, JUSTIN (PA-C)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:GARRISON
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 1:67 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-1328
Mailing Address - Country:US
Mailing Address - Phone:203-732-1256
Mailing Address - Fax:203-732-1539
Practice Address - Street 1:9 WASHINGTON AVE STE 3A
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3267
Practice Address - Country:US
Practice Address - Phone:475-227-3614
Practice Address - Fax:844-219-8679
Is Sole Proprietor?:No
Enumeration Date:2013-01-07
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08298363A00000X
CT5259363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8024NAOtherBCBS
TX316913801Medicaid
TX271830YKQHMedicare PIN