Healthcare Provider Details

I. General information

NPI: 1649886557
Provider Name (Legal Business Name): JUSTIN MATTHEW KNOX PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2020
Last Update Date: 03/03/2026
Certification Date: 03/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 W 22ND ST
ANDERSON IN
46016-4304
US

IV. Provider business mailing address

PO BOX 7527
DUBLIN OH
43017-0727
US

V. Phone/Fax

Practice location:
  • Phone: 765-641-7100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.006619
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10004559A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: