Provider Demographics
NPI:1982716585
Name:TALLENT, GREGORY DERRICK (PAC)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:DERRICK
Last Name:TALLENT
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 BLUE RIDGE RD STE 417
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-7516
Mailing Address - Country:US
Mailing Address - Phone:919-787-9097
Mailing Address - Fax:
Practice Address - Street 1:4420 LAKE BOONE TRL
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7505
Practice Address - Country:US
Practice Address - Phone:919-784-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021664363A00000X
SC1020363AM0700X
NC001000359363AM0700X
NC0010-00359363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1062Medicaid
NC02914OtherNC BCBS
SC1020OtherMEDICAL LICENSE
NC8902914Medicaid
CM7718OtherRAILROAD MEDICARE
NC02914OtherNC BCBS
4770Medicare ID - Type Unspecified
SCGP1062Medicaid