Healthcare Provider Details

I. General information

NPI: 1265488662
Provider Name (Legal Business Name): KENNETH PELLETIER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 08/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3404 WAKE FOREST RD STE 201
RALEIGH NC
27609-7341
US

IV. Provider business mailing address

3404 WAKE FOREST RD STE 201
RALEIGH NC
27609-7341
US

V. Phone/Fax

Practice location:
  • Phone: 919-256-1511
  • Fax: 919-256-1530
Mailing address:
  • Phone: 919-256-1511
  • Fax: 919-256-1530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number102579
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: