Provider Demographics
NPI:1619433042
Name:MEYER, JUSTIN NELSON (PA-C)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:NELSON
Last Name:MEYER
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 1:47220 VICTORIAN SQ N
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-6320
Mailing Address - Country:US
Mailing Address - Phone:734-770-8348
Mailing Address - Fax:
Practice Address - Street 1:7107 N WAYNE RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-2172
Practice Address - Country:US
Practice Address - Phone:734-578-0009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant