Basic Information
| Provider Information | |||||||||
| NPI: | 1811182710 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JUSTICE | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | CARLSON | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSPAP, PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CARLSON | ||||||||
| OtherFirstName: | HEATHER | ||||||||
| OtherMiddleName: | RUTH | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 105 W STONE DR | ||||||||
| Address2: | KINGSPORT | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376603365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234087220 | ||||||||
| FaxNumber: | 4234087405 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 W RAVINE RD | ||||||||
| Address2: | KINGSPORT | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376603837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232243150 | ||||||||
| FaxNumber: | 4232243169 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2007 | ||||||||
| LastUpdateDate: | 01/07/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA05331 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 5601006938 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 2863 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 0110005244 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.