Basic Information
| Provider Information | |||||||||
| NPI: | 1447526959 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTHSTAT INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HEALTHSTAT ON-SITE CLINIC/BRE WEST JEFFERSON | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| 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: | 2375 HWY 163 | ||||||||
| Address2: | |||||||||
| City: | WEST JEFFERSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28694 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362467138 | ||||||||
| FaxNumber: | 7049365570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2012 | ||||||||
| LastUpdateDate: | 03/29/2012 | ||||||||
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| AuthorizedOfficialLastName: | HUTTON | ||||||||
| AuthorizedOfficialFirstName: | WARREN | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 7045296161 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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.