Provider Demographics
NPI:1821033895
Name:JUSTUS, MATTHEW L (PA-C)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:L
Last Name:JUSTUS
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 1:16000 JOHNSTON MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24211-7659
Mailing Address - Country:US
Mailing Address - Phone:276-258-4050
Mailing Address - Fax:276-258-4056
Practice Address - Street 1:202 TOWN SQUARE ST.
Practice Address - Street 2:
Practice Address - City:GLADE SPRING
Practice Address - State:VA
Practice Address - Zip Code:24340
Practice Address - Country:US
Practice Address - Phone:276-429-1410
Practice Address - Fax:276-783-2879
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001912207PE0004X, 363A00000X
WV01170363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ007384Medicaid
VAP01198022OtherRR MEDICARE
VA1821033895Medicaid
Q58595Medicare UPIN
VAVAA113404Medicare PIN
VAVV6937AMedicare PIN