Healthcare Provider Details

I. General information

NPI: 1053511295
Provider Name (Legal Business Name): HEATHER M JUSTICE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2007
Last Update Date: 12/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 MARTIN LUTHER KING JR WAY
TACOMA WA
98405
US

IV. Provider business mailing address

PO BOX 661448
ARCADIA CA
91066-1448
US

V. Phone/Fax

Practice location:
  • Phone: 253-403-1050
  • Fax: 626-623-1227
Mailing address:
  • Phone: 626-447-0296
  • Fax: 626-623-1227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number29891
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberMD60170287
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: