Provider Demographics
NPI:1841787983
Name:PURNELL, JUSTIN PAUL (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:PAUL
Last Name:PURNELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 N SEGOE RD APT 509
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-3157
Mailing Address - Country:US
Mailing Address - Phone:859-866-2893
Mailing Address - Fax:
Practice Address - Street 1:619 N SEGOE RD APT 509
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-3157
Practice Address - Country:US
Practice Address - Phone:859-866-2893
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-14
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI73462-20207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program