Healthcare Provider Details

I. General information

NPI: 1053826669
Provider Name (Legal Business Name): ELYSE SHANNON POPE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2017
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1616 E MILLBROOK RD STE 140
RALEIGH NC
27609-4968
US

IV. Provider business mailing address

3505 SHEFFIELD DR
ROCKY MOUNT NC
27803-1231
US

V. Phone/Fax

Practice location:
  • Phone: 919-897-8784
  • Fax:
Mailing address:
  • Phone: 252-343-3796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-11927
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: