Healthcare Provider Details

I. General information

NPI: 1780691816
Provider Name (Legal Business Name): MICHELLE R PELLERIN P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6801 PHOENIX AVE STE 2
FORT SMITH AR
72903-5299
US

IV. Provider business mailing address

PO BOX 775641
CHICAGO IL
60677-5641
US

V. Phone/Fax

Practice location:
  • Phone: 479-384-5378
  • Fax: 479-385-5379
Mailing address:
  • Phone: 314-364-4200
  • Fax: 314-364-6321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-575
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA-575
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA-575
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: