Provider Demographics
NPI:1790781631
Name:PEARSON, KATHY D (PA)
Entity Type:Individual
Prefix:MS
First Name:KATHY
Middle Name:D
Last Name:PEARSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2624 ORTHO DR W
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-3484
Mailing Address - Country:US
Mailing Address - Phone:252-991-5261
Mailing Address - Fax:252-991-5262
Practice Address - Street 1:2624 ORTHO DR W
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-3484
Practice Address - Country:US
Practice Address - Phone:252-991-5261
Practice Address - Fax:252-991-5262
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001691363A00000X
NC001007703363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA71182POtherOPTIMA
VA71182POtherOPTIMA
VAQ33800Medicare UPIN