Provider Demographics
NPI:1609806801
Name:PEDACCHIO, MISTY (PA-C)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:PEDACCHIO
Suffix:
Gender:F
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 1:155 MEMORIAL DR
Mailing Address - Street 2:POST OFFICE BOX 3000
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-8710
Mailing Address - Country:US
Mailing Address - Phone:910-715-2164
Mailing Address - Fax:910-715-4493
Practice Address - Street 1:155 MEMORIAL DR
Practice Address - Street 2:POST OFFICE BOX 3000
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8710
Practice Address - Country:US
Practice Address - Phone:910-715-2164
Practice Address - Fax:910-715-4493
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103498363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2760964Medicare PIN
NC2760964BMedicare PIN
NC2760964AMedicare PIN