Provider Demographics
NPI:1790498582
Name:WALUKONIS, JUSTIN RICHARD
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:RICHARD
Last Name:WALUKONIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:739 MEADOWLAKE RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-1591
Mailing Address - Country:US
Mailing Address - Phone:248-933-2192
Mailing Address - Fax:
Practice Address - Street 1:739 MEADOWLAKE RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188-1591
Practice Address - Country:US
Practice Address - Phone:248-933-2192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-27
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704322121163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse