Provider Demographics
NPI:1265488662
Name:PELLETIER, KENNETH (PA-C)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:PELLETIER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3404 WAKE FOREST RD
Mailing Address - Street 2:STE 201
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-7341
Mailing Address - Country:US
Mailing Address - Phone:919-256-1511
Mailing Address - Fax:919-256-1530
Practice Address - Street 1:3404 WAKE FOREST RD
Practice Address - Street 2:STE 201
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7341
Practice Address - Country:US
Practice Address - Phone:919-256-1511
Practice Address - Fax:919-256-1530
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102579363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
568046Medicare UPIN
2749174BMedicare ID - Type Unspecified