Provider Demographics
NPI:1134910789
Name:EBERLE, JUSTIN (PA-C)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:EBERLE
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 1:1720 PHOENIX BLVD STE 900
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30349-5597
Mailing Address - Country:US
Mailing Address - Phone:404-631-6156
Mailing Address - Fax:
Practice Address - Street 1:4050 EXECUTIVE PARK DR
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45241-2089
Practice Address - Country:US
Practice Address - Phone:404-631-6156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-14
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.009410RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant