Basic Information
| Provider Information | |||||||||
| NPI: | 1164772372 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FENDER | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | MARCUS | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | R-NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 102 NW BOWENS MILL ROAD | ||||||||
| Address2: | |||||||||
| City: | DOUGLAS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315332252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123843838 | ||||||||
| FaxNumber: | 9123844029 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 PETERSON AVE N | ||||||||
| Address2: | SUITE C | ||||||||
| City: | DOUGLAS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315332832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123844000 | ||||||||
| FaxNumber: | 9123844029 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2012 | ||||||||
| LastUpdateDate: | 12/02/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN 194077 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 003128519F | 05 | GA | MEDICAID |