Healthcare Provider Details

I. General information

NPI: 1003558024
Provider Name (Legal Business Name): JUSTINA LI VEGA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2022
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

743 SPRING ST NE
GAINESVILLE GA
30501-3715
US

IV. Provider business mailing address

748 OLD NORCROSS RD STE 100
LAWRENCEVILLE GA
30046-3394
US

V. Phone/Fax

Practice location:
  • Phone: 770-533-7288
  • Fax: 770-534-9800
Mailing address:
  • Phone: 770-339-1500
  • Fax: 770-339-3528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number11301
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11301
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number11301
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: