Basic Information
Provider Information | |||||||||
NPI: | 1073519690 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GASKINS | ||||||||
FirstName: | RAYMOND | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 405 OWEN DR | ||||||||
Address2: |   | ||||||||
City: | FAYETTEVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 283043411 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9103233183 | ||||||||
FaxNumber: | 9107458478 | ||||||||
Practice Location | |||||||||
Address1: | 405 OWEN DR | ||||||||
Address2: |   | ||||||||
City: | FAYETTEVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 283043411 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9103233183 | ||||||||
FaxNumber: | 9102237555 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/28/2005 | ||||||||
LastUpdateDate: | 12/04/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/04/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X | 20544 | NC | N |   | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207QS1201X | 20544 | NC | N |   | Allopathic & Osteopathic Physicians | Family Medicine | Sleep Medicine | 207Q00000X | 20544 | NC | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 8934910 | 05 | NC |   | MEDICAID |