Provider Demographics
NPI:1629721931
Name:SHIN, JUSTINE Y
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:Y
Last Name:SHIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 STERLING BLVD APT 308
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-4839
Mailing Address - Country:US
Mailing Address - Phone:201-421-8731
Mailing Address - Fax:
Practice Address - Street 1:50 OLD FIELD POINT RD FL 3
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-6157
Practice Address - Country:US
Practice Address - Phone:203-862-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant