Basic Information
| Provider Information | |||||||||
| NPI: | 1538330220 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JUSTUS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | ANDY | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 HAWKINS DR | ||||||||
| Address2: | |||||||||
| City: | SEARCY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721434802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012782800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2900 HAWKINS DR | ||||||||
| Address2: | |||||||||
| City: | SEARCY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721434802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012782800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2008 | ||||||||
| LastUpdateDate: | 02/13/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA0000001589 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 1081760 | 01 | NCCPA | OTHER |