Basic Information
| Provider Information | |||||||||
| NPI: | 1053984013 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIPSEY | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | TYLER | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 CAMPUS BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 226012896 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5405365100 | ||||||||
| FaxNumber: | 5405360235 | ||||||||
| Practice Location | |||||||||
| Address1: | 611 E JUBAL EARLY DR | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 226015178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5405365500 | ||||||||
| FaxNumber: | 5405365507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2021 | ||||||||
| LastUpdateDate: | 06/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 0110007917 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.