Provider Demographics
NPI:1679977391
Name:PEVTSOV, EMILY BECKER (PA-C)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:BECKER
Last Name:PEVTSOV
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:FRANCES
Other - Last Name:BECKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:548 SANDHURST DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-4426
Mailing Address - Country:US
Mailing Address - Phone:910-484-3400
Mailing Address - Fax:910-484-3404
Practice Address - Street 1:548 SANDHURST DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4426
Practice Address - Country:US
Practice Address - Phone:910-484-3400
Practice Address - Fax:910-484-3404
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.005271363A00000X
NC0010-07412363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant