Basic Information
| Provider Information | |||||||||
| NPI: | 1326242397 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PESANTE | ||||||||
| FirstName: | MAISHA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2723 | ||||||||
| Address2: | |||||||||
| City: | ROCKY MOUNT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278022723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2522123486 | ||||||||
| FaxNumber: | 2522123497 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 S FAIRVIEW RD | ||||||||
| Address2: | |||||||||
| City: | ROCKY MOUNT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278016971 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524463333 | ||||||||
| FaxNumber: | 2524460426 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2007 | ||||||||
| LastUpdateDate: | 02/03/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 042.0013713 | VT | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 286857 | NY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | D82892 | MD | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | C1-0011962 | DE | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 01077907A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD21379 | ME | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 25MA10028800 | NJ | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD460049 | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 55962 | CT | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 4301111261 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD15634 | RI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 35.089492 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | E-12705 | AR | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 84764 | GA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2012-00930 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.