Provider Demographics
NPI:1952552291
Name:FAWELL, JUSTIN ROBERT (PA)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ROBERT
Last Name:FAWELL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5750 W VICKERY BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-7448
Mailing Address - Country:US
Mailing Address - Phone:817-732-2878
Mailing Address - Fax:817-732-9315
Practice Address - Street 1:5750 W VICKERY BLVD STE 104
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-7448
Practice Address - Country:US
Practice Address - Phone:817-732-2878
Practice Address - Fax:817-732-9315
Is Sole Proprietor?:No
Enumeration Date:2008-10-06
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19986363A00000X
TXPA10075363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant