Provider Demographics
NPI:1336410851
Name:EGOVILLE, JUSTIN (NP)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:EGOVILLE
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 1:257 WINDING WAY
Mailing Address - Street 2:
Mailing Address - City:MERION STATION
Mailing Address - State:PA
Mailing Address - Zip Code:19066-1225
Mailing Address - Country:US
Mailing Address - Phone:610-668-9528
Mailing Address - Fax:
Practice Address - Street 1:80001 STATE RD.
Practice Address - Street 2:MHM CORRECTIONAL SERVICES, MOD II
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19136-0000
Practice Address - Country:US
Practice Address - Phone:215-624-0797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-13
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP011762363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health