Provider Demographics
NPI:1205143567
Name:ANTHONY, JUSTIN ROBERT (PA-C)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ROBERT
Last Name:ANTHONY
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 1:7377 N ROGERS AVE
Mailing Address - Street 2:APT 206
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-5960
Mailing Address - Country:US
Mailing Address - Phone:847-477-7731
Mailing Address - Fax:
Practice Address - Street 1:9600 GROSS POINT RD
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1214
Practice Address - Country:US
Practice Address - Phone:847-933-6950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003783363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical