Provider Demographics
NPI:1720595077
Name:HASTINGS, CLYDE DONALD III (LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:CLYDE
Middle Name:DONALD
Last Name:HASTINGS
Suffix:III
Gender:M
Credentials:LAT, ATC
Other - Prefix:MR
Other - First Name:TRIPP
Other - Middle Name:
Other - Last Name:HASTINGS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:127 RAMSGATE DR
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28152-8509
Mailing Address - Country:US
Mailing Address - Phone:704-473-4788
Mailing Address - Fax:
Practice Address - Street 1:127 RAMSGATE DR
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28152-8509
Practice Address - Country:US
Practice Address - Phone:704-473-4788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-09
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLAT-35902255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCLAT-3590OtherNORTH CAROLINA BOARD OF ATHLETIC TRAINER EXAMINERS
2000020597OtherBOARD OF CERTIFICATION FOR THE ATHLETIC TRAINER