Basic Information
| Provider Information | |||||||||
| NPI: | 1679153225 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHARP | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
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| Credential: | CRM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1003 E MAIN ST STE 104 | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975047140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413264918 | ||||||||
| FaxNumber: | 5416082888 | ||||||||
| Practice Location | |||||||||
| Address1: | 1025 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975047689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417791282 | ||||||||
| FaxNumber: | 5417792081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2021 | ||||||||
| LastUpdateDate: | 04/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | 21-CRM-425 | OR | Y |
No ID Information.