Provider Demographics
NPI:1124605829
Name:GASTON, FARRAH NICOLE (DO)
Entity Type:Individual
Prefix:DR
First Name:FARRAH
Middle Name:NICOLE
Last Name:GASTON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 COUNTY ROAD 43
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:AL
Mailing Address - Zip Code:36726-3920
Mailing Address - Country:US
Mailing Address - Phone:334-412-6504
Mailing Address - Fax:
Practice Address - Street 1:530 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-0001
Practice Address - Country:US
Practice Address - Phone:334-412-6504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-27
Last Update Date:2021-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL390200000X390200000X
IL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program