Provider Demographics
NPI:1386851574
Name:FASTENAU, GEORGE CONRAD (NAVY IDC)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:CONRAD
Last Name:FASTENAU
Suffix:
Gender:M
Credentials:NAVY IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5179 COLORADO AVE
Mailing Address - Street 2:
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28547-1126
Mailing Address - Country:US
Mailing Address - Phone:910-451-7989
Mailing Address - Fax:
Practice Address - Street 1:2ND CEB BAS 2D MARDIV II MEF
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542
Practice Address - Country:US
Practice Address - Phone:910-451-7989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman