Provider Demographics
NPI:1912979329
Name:PELUSE, CHRISTIAN D (PA)
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:D
Last Name:PELUSE
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 1:16811 SOUTHWEST FREEWAY
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479
Mailing Address - Country:US
Mailing Address - Phone:281-690-4678
Mailing Address - Fax:
Practice Address - Street 1:16811 SOUTHWEST FREEWAY
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479
Practice Address - Country:US
Practice Address - Phone:281-690-4678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05622367A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8389NWOtherBLUE CROSS BLUE SHIELD
TX208248909Medicaid
TX208248911Medicaid
TX8548NTOtherBLUE CROSS BLUE SHIELD
TX503265ZSWDMedicare PIN
TX503265ZSVEMedicare PIN
TX208248909Medicaid
TX466086YQ64Medicare PIN