Healthcare Provider Details

I. General information

NPI: 1538008792
Provider Name (Legal Business Name): JUSTIN ROSS AGACNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 JESSE JEWELL PKWY NE STE 300
GAINESVILLE GA
30501-3875
US

IV. Provider business mailing address

PO BOX 742616
ATLANTA GA
30374-2616
US

V. Phone/Fax

Practice location:
  • Phone: 770-219-6520
  • Fax:
Mailing address:
  • Phone: 770-219-8420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN294820
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License NumberRN294820
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: