Provider Demographics
NPI:1336849652
Name:LENTZ, JUSTIN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:LENTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 METFIELD DR APT 2404
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-5309
Mailing Address - Country:US
Mailing Address - Phone:540-847-9592
Mailing Address - Fax:
Practice Address - Street 1:2335 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-4737
Practice Address - Country:US
Practice Address - Phone:321-593-0458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty