Provider Demographics
NPI:1578313037
Name:ROBERTSON, JUSTIN ASHLEY
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ASHLEY
Last Name:ROBERTSON
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 1:110 S SALEM DR
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-1761
Mailing Address - Country:US
Mailing Address - Phone:502-350-5081
Mailing Address - Fax:502-350-5095
Practice Address - Street 1:110 S SALEM DR
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-1761
Practice Address - Country:US
Practice Address - Phone:502-350-5081
Practice Address - Fax:502-350-5095
Is Sole Proprietor?:No
Enumeration Date:2024-03-26
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4015738363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily