Healthcare Provider Details

I. General information

NPI: 1154880813
Provider Name (Legal Business Name): FASTMED HOLDINGS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2019
Last Update Date: 03/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11491 US HIGHWAY 70, WEST SUITE B
CLAYTON NC
27520-5598
US

IV. Provider business mailing address

935 SHOTWELL RD STE 108
CLAYTON NC
27520-5598
US

V. Phone/Fax

Practice location:
  • Phone: 919-550-2584
  • Fax: 919-550-7059
Mailing address:
  • Phone: 919-550-2584
  • Fax: 919-882-9575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SHELLEY JANE STAYMATES
Title or Position: NAT. CREDENTIALING MANAGER
Credential:
Phone: 480-500-2285