Provider Demographics
NPI:1942232749
Name:CONCEPCION, JUSTO MARTIN (PA)
Entity Type:Individual
Prefix:MR
First Name:JUSTO
Middle Name:MARTIN
Last Name:CONCEPCION
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 1:2 WAGON WHEEL LN
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-5017
Mailing Address - Country:US
Mailing Address - Phone:917-517-5733
Mailing Address - Fax:
Practice Address - Street 1:2 WAGON WHEEL LN
Practice Address - Street 2:
Practice Address - City:DIX HILLS
Practice Address - State:NY
Practice Address - Zip Code:11746-5017
Practice Address - Country:US
Practice Address - Phone:917-517-5733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004903363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical