Provider Demographics
NPI:1891829693
Name:NOLEN, JUSTIN LEE (PA)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:LEE
Last Name:NOLEN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 388
Mailing Address - Street 2:
Mailing Address - City:FISHERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22939-0388
Mailing Address - Country:US
Mailing Address - Phone:540-932-5747
Mailing Address - Fax:540-932-5748
Practice Address - Street 1:70 MEDICAL CENTER CIR STE 305
Practice Address - Street 2:
Practice Address - City:FISHERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22939-2273
Practice Address - Country:US
Practice Address - Phone:540-932-5747
Practice Address - Fax:540-932-5748
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002178363A00000X
VA0110002718363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1891829693Medicaid