=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811432115
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FASTPASS UCM, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/22/2016
-----------------------------------------------------
Last Update Date | 12/22/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1080 E CARTWRIGHT RD SUITE 120
-----------------------------------------------------
City | MESQUITE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-275-9234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5300 TOWN AND COUNTRY BLVD SUITE 260
-----------------------------------------------------
City | FRISCO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75034-6894
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-320-9820
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. CARRIE DE MOOR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 214-275-9234
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------