Provider Demographics
NPI:1861505828
Name:JUSTUS, CAROLINE BROOKE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CAROLINE
Middle Name:BROOKE
Last Name:JUSTUS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:CAROLINE
Other - Middle Name:BROOKE
Other - Last Name:FLETCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 601643
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1643
Mailing Address - Country:US
Mailing Address - Phone:704-302-8200
Mailing Address - Fax:704-302-8201
Practice Address - Street 1:3030 RANDOLPH RD
Practice Address - Street 2:SUITE 200, MMG MUSEUM
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1368
Practice Address - Country:US
Practice Address - Phone:704-302-8200
Practice Address - Fax:704-302-8201
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103732363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8101156Medicaid
SC0189PAMedicaid
NC1861505828Medicaid
NC8101156Medicaid
SC0189PAMedicaid