Provider Demographics
NPI:1649004557
Name:PELTON, HISAYO HARA (CNP)
Entity type:Individual
Prefix:MS
First Name:HISAYO
Middle Name:HARA
Last Name:PELTON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8418 LULLWATER DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75218-1150
Mailing Address - Country:US
Mailing Address - Phone:214-732-7557
Mailing Address - Fax:
Practice Address - Street 1:8418 LULLWATER DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75218-1150
Practice Address - Country:US
Practice Address - Phone:214-503-0590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-02
Last Update Date:2024-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1144651207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine