Provider Demographics
NPI:1770322737
Name:HEADDEN, PEYTON RAY
Entity type:Individual
Prefix:
First Name:PEYTON
Middle Name:RAY
Last Name:HEADDEN
Suffix:
Gender:F
Credentials:
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 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-764-2324
Mailing Address - Fax:336-764-9541
Practice Address - Street 1:12208 N NC HIGHWAY 150
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27127-9730
Practice Address - Country:US
Practice Address - Phone:336-764-2324
Practice Address - Fax:336-764-9541
Is Sole Proprietor?:No
Enumeration Date:2024-05-20
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-14365363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant