Healthcare Provider Details

I. General information

NPI: 1730943663
Provider Name (Legal Business Name): AUSTIN FANN FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2024
Last Update Date: 02/12/2024
Certification Date: 02/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 OLD ROBERTS RD # 102
BENSON NC
27504-8047
US

IV. Provider business mailing address

1145 MCPHAIL RD
ROSEBORO NC
28382-7066
US

V. Phone/Fax

Practice location:
  • Phone: 919-934-2600
  • Fax:
Mailing address:
  • Phone: 910-214-6792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5019605
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: