Healthcare Provider Details

I. General information

NPI: 1316295652
Provider Name (Legal Business Name): JUSTIN W. LATIMER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2012
Last Update Date: 01/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 E MARSHALL ST DEPT. OF ORTHOPAEDIC SURGERY
RICHMOND VA
23298-5051
US

IV. Provider business mailing address

PO BOX 91734
RICHMOND VA
23291-1734
US

V. Phone/Fax

Practice location:
  • Phone: 804-828-7069
  • Fax: 804-828-4762
Mailing address:
  • Phone: 804-358-6100
  • Fax: 804-342-7619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110003925
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: