Provider Demographics
NPI:1457369647
Name:DEVUYST, PETER R (PA)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:R
Last Name:DEVUYST
Suffix:
Gender:M
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:PO BOX 603725
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3725
Mailing Address - Country:US
Mailing Address - Phone:828-575-2625
Mailing Address - Fax:828-350-2174
Practice Address - Street 1:339 RACETRACK RD NW
Practice Address - Street 2:SUITE 17
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1538
Practice Address - Country:US
Practice Address - Phone:850-863-1189
Practice Address - Fax:850-863-1241
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9100656363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE1814WOtherMEDICARE PTAN
FL013809000Medicaid
E1814WMedicare PIN