Provider Demographics
NPI:1922078831
Name:CONDREY, STACI FAULKNER (MD)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:FAULKNER
Last Name:CONDREY
Suffix:
Gender:F
Credentials:MD
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 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3020 WEDDINGTON RD
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-8158
Practice Address - Country:US
Practice Address - Phone:704-403-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9900192208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1993730OtherUNITED HEALTHCARE
NC470108OtherMAMSI
NC208776473013OtherTRICARE
NC88478OtherMEDCOST
NC142380OtherWELLPATH
NC30112OtherPARTNERS MEDICARE CHOICE
NC2273518BOtherMEDICARE PTAN
NC019FHOtherBCBSNC
5964724OtherAETNA
NC1207QOtherBCBS
NC891207QMedicaid
NC2273518AMedicare ID - Type UnspecifiedMEDICARE
NC2273518BOtherMEDICARE PTAN