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General NPI Number Information
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NPI Number | 1366120982
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Entity Type | Individual
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Provider Name | JUSTIN PATRICK PA
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Gender | Male
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Dates
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Enumeration Date | 07/05/2023
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Last Update Date | 10/18/2023
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Provider Practice Location Address
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Address Line | 24725 W 12 MILE RD STE 260
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City | SOUTHFIELD
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State | MI
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Zip | 48034-8310
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Country | US
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Telephone | 248-382-8052
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Fax |
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Provider Business Mailing Address
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Address Line | 2701 PARK AVE
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City | DETROIT
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State | MI
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Zip | 48201-3041
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 5601011860
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License Number State | MI
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