Provider Demographics
NPI:1487282133
Name:BALASUBRAMANIAN, JUSTINE LYNN (PA-C)
Entity type:Individual
Prefix:
First Name:JUSTINE
Middle Name:LYNN
Last Name:BALASUBRAMANIAN
Suffix:
Gender:F
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:MEDICAL CENTER BVLD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-0001
Mailing Address - Country:US
Mailing Address - Phone:336-716-9252
Mailing Address - Fax:336-716-0030
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-5021
Practice Address - Country:US
Practice Address - Phone:336-716-9252
Practice Address - Fax:336-716-0030
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-30
Last Update Date:2025-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025636363A00000X
NC0010-15522363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty