Provider Demographics
NPI:1881020295
Name:KWON, JUSTIN K (PA-C)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:K
Last Name:KWON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 1ST ST E
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:TN
Mailing Address - Zip Code:38069-4426
Mailing Address - Country:US
Mailing Address - Phone:731-548-2232
Mailing Address - Fax:731-548-2236
Practice Address - Street 1:17 1ST ST E
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:TN
Practice Address - Zip Code:38069-4426
Practice Address - Country:US
Practice Address - Phone:731-548-2232
Practice Address - Fax:731-548-2236
Is Sole Proprietor?:No
Enumeration Date:2013-09-17
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2404363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNPA2404OtherSTATE LICENSE