Provider Demographics
NPI:1720353261
Name:BROWN, JUSTIN MARSHALL (CSA)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:MARSHALL
Last Name:BROWN
Suffix:
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 HUNT RD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-5667
Mailing Address - Country:US
Mailing Address - Phone:585-356-5619
Mailing Address - Fax:
Practice Address - Street 1:92 HUNT RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-5667
Practice Address - Country:US
Practice Address - Phone:585-356-5619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-16
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYSA237246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant