Basic Information
| Provider Information | |||||||||
| NPI: | 1518354554 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PELLETIER | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | CONRAD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3010 BEARD RD | ||||||||
| Address2: | |||||||||
| City: | NAPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945583442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072558825 | ||||||||
| FaxNumber: | 7072559325 | ||||||||
| Practice Location | |||||||||
| Address1: | 5555 PEACHTREE DUNWOODY RD STE G65 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048433323 | ||||||||
| FaxNumber: | 4045745944 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2015 | ||||||||
| LastUpdateDate: | 10/20/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | A148657 | CA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.