Provider Demographics
NPI:1639366321
Name:EHMKE, JUSTIN (PA-C)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:EHMKE
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 1:21321 E OCOTILLO RD STE 118
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85242-5994
Mailing Address - Country:US
Mailing Address - Phone:480-458-5135
Mailing Address - Fax:480-458-5241
Practice Address - Street 1:21321 E OCOTILLO RD STE 118
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85242-5994
Practice Address - Country:US
Practice Address - Phone:480-458-5135
Practice Address - Fax:480-458-5241
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3676363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical