Basic Information
| Provider Information | |||||||||
| NPI: | 1225703036 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | JUSTICE | ||||||||
| FirstName: | ADAM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11146 WESTHAVEN CIR | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757620320 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1453 E BERT KOUN LOOP | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711056800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186814500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2021 | ||||||||
| LastUpdateDate: | 08/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 220881 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.