Provider Demographics
NPI:1104152479
Name:MIZE, JUSTIN R (PA)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:R
Last Name:MIZE
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Gender:M
Credentials:PA
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Mailing Address - Street 1:PO BOX 7549
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-0549
Mailing Address - Country:US
Mailing Address - Phone:757-686-3515
Mailing Address - Fax:757-686-0541
Practice Address - Street 1:4092 FOXWOOD DR
Practice Address - Street 2:SUITE 101
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-5225
Practice Address - Country:US
Practice Address - Phone:757-467-4200
Practice Address - Fax:757-686-0541
Is Sole Proprietor?:No
Enumeration Date:2009-10-21
Last Update Date:2022-10-25
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Provider Licenses
StateLicense IDTaxonomies
VA0110003168363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
021838E07Medicare PIN