Provider Demographics
NPI:1922022938
Name:PELLEGRINO, CANDICE ROSEANNE (MPAC, PA-C)
Entity Type:Individual
Prefix:MS
First Name:CANDICE
Middle Name:ROSEANNE
Last Name:PELLEGRINO
Suffix:
Gender:F
Credentials:MPAC, 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:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-8800
Mailing Address - Fax:
Practice Address - Street 1:302 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78665-1032
Practice Address - Country:US
Practice Address - Phone:512-509-0200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01105363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1821185299OtherAGENCY (BVCAA, INC.) NPI
TX1821185299OtherAGENCY (BVCAA, INC.) NPI