Provider Demographics
NPI:1154762748
Name:CECIL, JUSTIN B (PA-C)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:B
Last Name:CECIL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 W MAIN ST STE 202
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422-1876
Mailing Address - Country:US
Mailing Address - Phone:859-238-7746
Mailing Address - Fax:859-236-0261
Practice Address - Street 1:236 W MAIN ST STE 202
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-1876
Practice Address - Country:US
Practice Address - Phone:859-238-7746
Practice Address - Fax:859-236-0261
Is Sole Proprietor?:No
Enumeration Date:2013-07-11
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC199363A00000X
KYPA1806363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical