Provider Demographics
NPI:1649643982
Name:SMITH, JUSTIN (PA-C)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2828 1ST AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25702-1236
Mailing Address - Country:US
Mailing Address - Phone:304-525-6905
Mailing Address - Fax:304-525-4316
Practice Address - Street 1:2828 1ST AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25702-1236
Practice Address - Country:US
Practice Address - Phone:304-525-6905
Practice Address - Fax:304-525-4316
Is Sole Proprietor?:No
Enumeration Date:2015-11-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1955363A00000X
OH50.004527363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant