Provider Demographics
NPI:1730831132
Name:GREGORY, JUSTIN WESLEY
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:WESLEY
Last Name:GREGORY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 LAKE MARIE RD
Mailing Address - Street 2:
Mailing Address - City:GALLATIN
Mailing Address - State:TN
Mailing Address - Zip Code:37066-8701
Mailing Address - Country:US
Mailing Address - Phone:615-979-7757
Mailing Address - Fax:
Practice Address - Street 1:375 S KISHACOQUILLAS ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:PA
Practice Address - Zip Code:17004-8620
Practice Address - Country:US
Practice Address - Phone:717-935-2065
Practice Address - Fax:717-935-5560
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-26
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant