Provider Demographics
NPI:1841236353
Name:PECEVICH, LOUISE ANN (PA)
Entity type:Individual
Prefix:
First Name:LOUISE
Middle Name:ANN
Last Name:PECEVICH
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 1:159 RIVERCHASE RD
Mailing Address - Street 2:
Mailing Address - City:PINNACLE
Mailing Address - State:NC
Mailing Address - Zip Code:27043-8515
Mailing Address - Country:US
Mailing Address - Phone:843-209-6704
Mailing Address - Fax:
Practice Address - Street 1:2110 DORCHESTER AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02124-5628
Practice Address - Country:US
Practice Address - Phone:843-209-6704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363A00000X363A00000X
MAPA2582363AM0700X
NC103743363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2763594CMedicare PIN
NCP94387Medicare UPIN