Basic Information
Provider Information | |||||||||
NPI: | 1821033895 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JUSTUS | ||||||||
FirstName: | MATTHEW | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 16000 JOHNSTON MEMORIAL DR | ||||||||
Address2: |   | ||||||||
City: | ABINGDON | ||||||||
State: | VA | ||||||||
PostalCode: | 242117659 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2762584050 | ||||||||
FaxNumber: | 2762584056 | ||||||||
Practice Location | |||||||||
Address1: | 202 TOWN SQUARE ST. | ||||||||
Address2: |   | ||||||||
City: | GLADE SPRING | ||||||||
State: | VA | ||||||||
PostalCode: | 24340 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2764291410 | ||||||||
FaxNumber: | 2767832879 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/16/2006 | ||||||||
LastUpdateDate: | 05/20/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/04/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | 0110001912 | VA | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 363A00000X | 01170 | WV | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363A00000X | 0110001912 | VA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | Q007384 | 05 | TN |   | MEDICAID | P01198022 | 01 | VA | RR MEDICARE | OTHER | 1821033895 | 05 | VA |   | MEDICAID |