Provider Demographics
NPI:1316656481
Name:GASTON FAMILY PRACTICE PLLC
Entity type:Organization
Organization Name:GASTON FAMILY PRACTICE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:REED
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:704-867-1402
Mailing Address - Street 1:2290 REMOUNT RD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-4725
Mailing Address - Country:US
Mailing Address - Phone:704-867-1402
Mailing Address - Fax:704-671-2028
Practice Address - Street 1:2290 REMOUNT RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-4725
Practice Address - Country:US
Practice Address - Phone:704-867-1402
Practice Address - Fax:888-720-2814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-17
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1306896147Medicaid
NC1629271440Medicaid
NC1912930009Medicaid