Healthcare Provider Details

I. General information

NPI: 1790095537
Provider Name (Legal Business Name): JAMES JUNIOUS PILGRIM III CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2010
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1638 OWEN DR
FAYETTEVILLE NC
28304-3424
US

IV. Provider business mailing address

PO BOX 40908
FAYETTEVILLE NC
28309-0908
US

V. Phone/Fax

Practice location:
  • Phone: 910-615-5132
  • Fax: 910-321-6236
Mailing address:
  • Phone: 910-615-6448
  • Fax: 910-615-5070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number085579
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number211027
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: