Basic Information
| Provider Information | |||||||||
| NPI: | 1336778406 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORSLINE | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2525 DESALES AVE | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374041161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234952525 | ||||||||
| FaxNumber: | 4234952625 | ||||||||
| Practice Location | |||||||||
| Address1: | 2051 HAMILL RD | ||||||||
| Address2: | |||||||||
| City: | HIXSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373436614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237751121 | ||||||||
| FaxNumber: | 4234952625 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2020 | ||||||||
| LastUpdateDate: | 04/01/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 27367 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.