MEDICARE: PEGASUS PRIMARY PROVIDERS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner

General Provider Information

NPI Number	:	1982486395
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEGASUS PRIMARY PROVIDERS, LLC

Provider Business Mailing Address
First Line	:	PO BOX 2716
Second Line	:
City	:	WEST MONROE
State	:	LA
Zip	:	71294-2716
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4624 CYPRESS ST STE 7
Second Line	:
City	:	WEST MONROE
State	:	LA
Zip	:	71291-1348
Country	:	US
Telephone Number	:	318-325-6200
Fax Number	:	318-998-7348

Authorized Official
Title or Position	:	OWNER/PROVIDER
Name	:	GLENDA SHERRY PEVETO
Credential	:	FNP
Telephone Number	:	318-325-6200

Provider Enumeration Date	:	10/19/2023
Last Update Date	:	10/19/2023

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