Healthcare Provider Details

I. General information

NPI: 1336879642
Provider Name (Legal Business Name): VICTOR MAURICIO PEREIRA SR. PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2022
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

923 W 3RD ST STE C
PEMBROKE NC
28372-9629
US

IV. Provider business mailing address

1738 OWEN DR STE 110-111
FAYETTEVILLE NC
28304-3877
US

V. Phone/Fax

Practice location:
  • Phone: 910-521-0564
  • Fax: 910-521-4088
Mailing address:
  • Phone: 910-499-0616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0010-12306
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number0010-12306
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: