Provider Demographics
NPI:1578892519
Name:GENSON, JUSTIN DANIEL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:DANIEL
Last Name:GENSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2515 W ELK AVE
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:OK
Mailing Address - Zip Code:73533-1571
Mailing Address - Country:US
Mailing Address - Phone:580-470-2916
Mailing Address - Fax:580-470-2966
Practice Address - Street 1:2515 W ELK AVE
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:OK
Practice Address - Zip Code:73533-1571
Practice Address - Country:US
Practice Address - Phone:580-470-2916
Practice Address - Fax:580-470-2966
Is Sole Proprietor?:No
Enumeration Date:2009-12-23
Last Update Date:2010-04-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OKPA1867363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant