Provider Demographics
NPI:1790706620
Name:PESCHONG, DONALD FRANCIS (PA-C)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:FRANCIS
Last Name:PESCHONG
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 1:138 MEMORY PLZ
Mailing Address - Street 2:
Mailing Address - City:WHITEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28472-2640
Mailing Address - Country:US
Mailing Address - Phone:910-207-6218
Mailing Address - Fax:910-207-6219
Practice Address - Street 1:402 N PINE ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-5563
Practice Address - Country:US
Practice Address - Phone:910-739-1666
Practice Address - Fax:910-739-6822
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-23
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103596363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0982PAMedicaid
NC1790706620Medicaid
NC1790706620Medicaid
NCNC7009BMedicare PIN
R04619Medicare UPIN