Provider Demographics
NPI:1639887193
Name:PERDOMO, JUANITA (PA-C)
Entity Type:Individual
Prefix:
First Name:JUANITA
Middle Name:
Last Name:PERDOMO
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 1:1001 MANCHESTER DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-5152
Mailing Address - Country:US
Mailing Address - Phone:704-839-9336
Mailing Address - Fax:
Practice Address - Street 1:2406 BLUE RIDGE RD STE 205
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6666
Practice Address - Country:US
Practice Address - Phone:919-782-4884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-12669363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant