Healthcare Provider Details

I. General information

NPI: 1407902059
Provider Name (Legal Business Name): GENERATIONS FAMILY PRACTICE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 12/08/2021
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 DARRINGTON DR STE 101
CARY NC
27513-8158
US

IV. Provider business mailing address

1021 DARRINGTON DR STE 101
CARY NC
27513-8158
US

V. Phone/Fax

Practice location:
  • Phone: 919-852-3999
  • Fax: 919-825-3444
Mailing address:
  • Phone: 919-852-3999
  • Fax: 919-825-3444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number28064
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY LONG
Title or Position: CREDENTIALING/ENROLLMENT SPECIALIST
Credential:
Phone: 984-333-2741