Provider Demographics
NPI:1710932488
Name:JUSTICE, SARAH M (PAC)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:M
Last Name:JUSTICE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:M
Other - Last Name:BURKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:WHITESBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41858-0040
Mailing Address - Country:US
Mailing Address - Phone:606-633-4823
Mailing Address - Fax:
Practice Address - Street 1:226 MEDICAL PLAZA LN
Practice Address - Street 2:
Practice Address - City:WHITESBURG
Practice Address - State:KY
Practice Address - Zip Code:41858-7425
Practice Address - Country:US
Practice Address - Phone:606-633-4871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA848363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95004727Medicaid
Q23573Medicare UPIN
KY0201696Medicare ID - Type Unspecified
KY95004727Medicaid