Provider Demographics
NPI:1720370117
Name:JUSTINO, CHRISTOPHER SCOTT (PA)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:SCOTT
Last Name:JUSTINO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-5849
Mailing Address - Fax:
Practice Address - Street 1:1520 SAN PABLO STREET
Practice Address - Street 2:SUITE 4300
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5324
Practice Address - Country:US
Practice Address - Phone:323-442-5849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-04
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21363363AS0400X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFM071ZMedicare PIN