Healthcare Provider Details

I. General information

NPI: 1861316259
Provider Name (Legal Business Name): JUSTINE HAZELCORN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1316 SW 25TH AVE
FORT LAUDERDALE FL
33312-3936
US

IV. Provider business mailing address

1316 SW 25TH AVE
FORT LAUDERDALE FL
33312-3936
US

V. Phone/Fax

Practice location:
  • Phone: 561-929-7798
  • Fax:
Mailing address:
  • Phone: 561-929-7798
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: