Provider Demographics
NPI:1265897789
Name:COLE, JUSTIN (PA-C)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:COLE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1000, DEPT 960
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:901-272-6030
Mailing Address - Fax:901-516-8450
Practice Address - Street 1:1325 EASTMORELAND AVE STE 365
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-7542
Practice Address - Country:US
Practice Address - Phone:901-272-6030
Practice Address - Fax:901-516-8450
Is Sole Proprietor?:No
Enumeration Date:2015-12-28
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN2959363A00000X
SC4967363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant