Provider Demographics
NPI:1710735964
Name:STANFIELD, GARRAD
Entity type:Individual
Prefix:
First Name:GARRAD
Middle Name:
Last Name:STANFIELD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 RAINY LAKE ST
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-3419
Mailing Address - Country:US
Mailing Address - Phone:984-297-4167
Mailing Address - Fax:
Practice Address - Street 1:2040 RAINY LAKE ST
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-3419
Practice Address - Country:US
Practice Address - Phone:984-297-4167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-10
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20889954305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization