Provider Demographics
NPI:1366402471
Name:FASTLE, REBECCA K
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:K
Last Name:FASTLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 BRADBURY DR SE STE 116
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4310
Mailing Address - Country:US
Mailing Address - Phone:505-272-1476
Mailing Address - Fax:
Practice Address - Street 1:UNM DEPARTMENT OF EM MSC II
Practice Address - Street 2:1 UNIVERSITY OF NM
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-0001
Practice Address - Country:US
Practice Address - Phone:505-272-5062
Practice Address - Fax:505-272-6503
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2025-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM98-255207P00000X, 2080P0204X
TXL2245207P00000X, 2080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8317K3Medicare PIN
TX81918SOtherBCBS
TX146755701Medicaid
TX146755702Medicaid