Healthcare Provider Details

I. General information

NPI: 1689510331
Provider Name (Legal Business Name): JUSTIN AMMAR MYERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7219 YORKSHIRE ST
JOLIET IL
60431-8092
US

IV. Provider business mailing address

7219 YORKSHIRE ST
JOLIET IL
60431-8092
US

V. Phone/Fax

Practice location:
  • Phone: 779-875-3559
  • Fax:
Mailing address:
  • Phone: 779-875-3559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: