Provider Demographics
NPI:1689895245
Name:MCADOO, JUSTIN (DNP, CRNA, PMHNP-BC)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:
Last Name:MCADOO
Suffix:
Gender:M
Credentials:DNP, CRNA, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:871 RIDGEWAY LOOP RD STE 108
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-4026
Mailing Address - Country:US
Mailing Address - Phone:901-871-0170
Mailing Address - Fax:
Practice Address - Street 1:871 RIDGEWAY LOOP RD STE 108
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-4026
Practice Address - Country:US
Practice Address - Phone:901-871-0170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC003113367500000X
TN12785367500000X, 363LP0808X
TNRN141683163W00000X
TNAPN 12785367500000X
MS901353367500000X
TN141683163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1689895245OtherRAILROAD MEDICARE
TN3600050Medicaid
AR167862001Medicaid
AR84525OtherBCBSAR
TN4156663OtherBCBSTN
MS08254702Medicaid
TN3600050Medicare PIN