Provider Demographics
NPI:1164610143
Name:JUSTAFORT, FLAVIE LESAGE (PA)
Entity type:Individual
Prefix:
First Name:FLAVIE
Middle Name:LESAGE
Last Name:JUSTAFORT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 W LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17603-2798
Mailing Address - Country:US
Mailing Address - Phone:179-783-0527
Mailing Address - Fax:717-824-3204
Practice Address - Street 1:313 W LIBERTY ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17603-2798
Practice Address - Country:US
Practice Address - Phone:717-978-3052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-04
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053246363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA128476Medicare PIN