Provider Demographics
NPI:1720119753
Name:DY, JUSTIN JASON
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:JASON
Last Name:DY
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 1:1224 W ROSEBURG AVE
Mailing Address - Street 2:A
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4981
Mailing Address - Country:US
Mailing Address - Phone:209-569-0150
Mailing Address - Fax:
Practice Address - Street 1:1224 W ROSEBURG AVE
Practice Address - Street 2:A
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4981
Practice Address - Country:US
Practice Address - Phone:209-569-0150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA605577163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant