Provider Demographics
NPI:1457604944
Name:EVERSON, JUSTIN COLIN (MMS, PA-C)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:COLIN
Last Name:EVERSON
Suffix:
Gender:M
Credentials:MMS, 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:BUILDING 19H, ROOM 270
Mailing Address - Street 2:PERRY POINT VA MEDICAL CENTER
Mailing Address - City:PERRY POINT
Mailing Address - State:MD
Mailing Address - Zip Code:21902
Mailing Address - Country:US
Mailing Address - Phone:410-642-2411
Mailing Address - Fax:410-642-1898
Practice Address - Street 1:10755 FALLS RD STE 160
Practice Address - Street 2:
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-4588
Practice Address - Country:US
Practice Address - Phone:410-583-2777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-21
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0004855207RA0401X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine