Provider Demographics
NPI:1154840098
Name:UNRUH, JUSTINE ALYSS
Entity type:Individual
Prefix:MRS
First Name:JUSTINE
Middle Name:ALYSS
Last Name:UNRUH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 FRONTIS PLAZA BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-5663
Mailing Address - Country:US
Mailing Address - Phone:336-768-6211
Mailing Address - Fax:
Practice Address - Street 1:18707 HARDY OAK BLVD STE 225
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4869
Practice Address - Country:US
Practice Address - Phone:210-614-1234
Practice Address - Fax:210-614-0952
Is Sole Proprietor?:No
Enumeration Date:2017-09-12
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA17501363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant