Provider Demographics
NPI:1326216334
Name:FAST, AMY (LSW)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:
Last Name:FAST
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1995
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58502-1995
Mailing Address - Country:US
Mailing Address - Phone:701-222-2598
Mailing Address - Fax:
Practice Address - Street 1:1120 LARAMIE DR
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-6373
Practice Address - Country:US
Practice Address - Phone:701-222-2598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-12
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3281171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND27507OtherBLUECROSS/BLUESHIELD
ND74005Medicaid