Provider Demographics
NPI:1235864190
Name:FIRTH, JUSTIN G
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:G
Last Name:FIRTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2520 S 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-1923
Mailing Address - Country:US
Mailing Address - Phone:208-233-5433
Mailing Address - Fax:
Practice Address - Street 1:2520 S 5TH AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204-1923
Practice Address - Country:US
Practice Address - Phone:208-233-5433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1461674363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant