Basic Information
Provider Information | |||||||||
NPI: | 1083980593 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HEALTHSTAT INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HEALTHSTAT ON-SITE CLINIC/BRE SPARTA | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4601 CHARLOTTE PARK DR | ||||||||
Address2: | SUITE 390 | ||||||||
City: | CHARLOTTE | ||||||||
State: | NC | ||||||||
PostalCode: | 282171915 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7045296161 | ||||||||
FaxNumber: | 7049365570 | ||||||||
Practice Location | |||||||||
Address1: | 1889 HWY 21 S. | ||||||||
Address2: |   | ||||||||
City: | SPARTA | ||||||||
State: | NC | ||||||||
PostalCode: | 28675 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8287582382 | ||||||||
FaxNumber: | 3363725734 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/29/2012 | ||||||||
LastUpdateDate: | 03/29/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HUTTON | ||||||||
AuthorizedOfficialFirstName: | WARREN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | COO | ||||||||
AuthorizedOfficialTelephone: | 7045296161 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No ID Information.