Provider Demographics
NPI:1619012689
Name:JUSTINIANI, MARY GRACE CABATAS (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY GRACE
Middle Name:CABATAS
Last Name:JUSTINIANI
Suffix:
Gender:F
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 1:19120 JOVAN ST
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-6710
Mailing Address - Country:US
Mailing Address - Phone:818-758-0243
Mailing Address - Fax:
Practice Address - Street 1:14044 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401-2226
Practice Address - Country:US
Practice Address - Phone:818-376-0405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 17249363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant