Healthcare Provider Details

I. General information

NPI: 1518262039
Provider Name (Legal Business Name): JUSTIN DEAN LATINO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2011
Last Update Date: 11/16/2022
Certification Date: 11/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4092 FOXWOOD DR SUITE 101
VIRGINIA BEACH VA
23462-5225
US

IV. Provider business mailing address

4092 FOXWOOD DRIVE SUITE 101
VIRGINIA BEACH VIRGINIA
23462
UM

V. Phone/Fax

Practice location:
  • Phone: 757-467-4200
  • Fax:
Mailing address:
  • Phone: 757-467-4200
  • Fax: 757-467-4173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110003499
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: