Healthcare Provider Details

I. General information

NPI: 1487046850
Provider Name (Legal Business Name): KYLE GILMORE PELLIGRA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2015
Last Update Date: 10/16/2023
Certification Date: 11/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7228 PITTSBORO-MONCURE RD
MONCURE NC
27559
US

IV. Provider business mailing address

7228 PITTSBORO-MONCURE RD
MONCURE NC
27559
US

V. Phone/Fax

Practice location:
  • Phone: 919-542-4991
  • Fax: 919-542-3726
Mailing address:
  • Phone: 919-542-4991
  • Fax: 919-542-3726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0010-05500
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-05500
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: