Provider Demographics
NPI:1942433180
Name:JUSTICE, AMY ALLYN (PA-C)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:ALLYN
Last Name:JUSTICE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:AMY
Other - Middle Name:ALLYN
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 ABRAHAM FLEXNER WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-2877
Practice Address - Country:US
Practice Address - Phone:502-852-5689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-03
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1218363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100105060Medicaid
0572141Medicare PIN