Provider Demographics
NPI:1205539293
Name:SOUTER, JUSTIN (NP)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:SOUTER
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 CHARLIE MORRIS RD
Mailing Address - Street 2:
Mailing Address - City:COLBERT
Mailing Address - State:GA
Mailing Address - Zip Code:30628-2445
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11 CHARLIE MORRIS RD
Practice Address - Street 2:
Practice Address - City:COLBERT
Practice Address - State:GA
Practice Address - Zip Code:30628-2445
Practice Address - Country:US
Practice Address - Phone:706-521-3113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-27
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA306248363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily