Basic Information
| Provider Information | |||||||||
| NPI: | 1154880813 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FASTMED HOLDINGS, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 935 SHOTWELL RD STE 108 | ||||||||
| Address2: | |||||||||
| City: | CLAYTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275205598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195502584 | ||||||||
| FaxNumber: | 9198829575 | ||||||||
| Practice Location | |||||||||
| Address1: | 11491 US HIGHWAY 70, WEST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | CLAYTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275205598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195502584 | ||||||||
| FaxNumber: | 9195507059 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2019 | ||||||||
| LastUpdateDate: | 03/13/2019 | ||||||||
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| AuthorizedOfficialLastName: | STAYMATES | ||||||||
| AuthorizedOfficialFirstName: | SHELLEY | ||||||||
| AuthorizedOfficialMiddleName: | JANE | ||||||||
| AuthorizedOfficialTitleorPosition: | NAT. CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4805002285 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.