Provider Demographics
NPI:1154516722
Name:JUSTICE, BRENDA JEAN (PAC)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:JEAN
Last Name:JUSTICE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BENSON
Mailing Address - State:NC
Mailing Address - Zip Code:27504-1506
Mailing Address - Country:US
Mailing Address - Phone:919-894-3321
Mailing Address - Fax:919-894-8742
Practice Address - Street 1:125 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BENSON
Practice Address - State:NC
Practice Address - Zip Code:27504-1506
Practice Address - Country:US
Practice Address - Phone:919-894-3321
Practice Address - Fax:919-894-8742
Is Sole Proprietor?:No
Enumeration Date:2007-09-07
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC179133OtherWELLPATH
NC89012Y9Medicaid
NC7389999OtherMAMSI
NC012Y9OtherBLUE CROSS/BLUE SHIELD
NC3604325OtherCIGNA
NC89014KXMedicaid
NC89012Y9Medicaid