Provider Demographics
NPI:1316198229
Name:NKYESIGA, PETER KANKAKA (PA)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:KANKAKA
Last Name:NKYESIGA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9332 S TRYON ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-3108
Practice Address - Country:US
Practice Address - Phone:704-587-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-09
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-03018363A00000X, 363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1316198229Medicaid
SC1453PAMedicaid
NC8102076Medicaid
NCNC7721EMedicare PIN
NCNC7721FMedicare PIN
NCNC7721NMedicare PIN
NCNC7721CMedicare PIN
NCNC7721BMedicare PIN
NCNC7721HMedicare PIN
NC8102076Medicaid
NC1316198229Medicaid
SCSC87027772Medicare PIN
NCNC7721KMedicare PIN
NCNC7721AMedicare PIN
NCNC7721DMedicare PIN
NCNC7721OMedicare PIN
NCNC7721GMedicare PIN
NCNC7721LMedicare PIN
NCNC7721JMedicare PIN