Basic Information
| Provider Information | |||||||||
| NPI: | 1912979329 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PELUSE | ||||||||
| FirstName: | CHRISTIAN | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16811 SOUTHWEST FREEWAY | ||||||||
| Address2: | |||||||||
| City: | SUGAR LAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77479 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2816904678 | ||||||||
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| Practice Location | |||||||||
| Address1: | 16811 SOUTHWEST FREEWAY | ||||||||
| Address2: | |||||||||
| City: | SUGAR LAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77479 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2816904678 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2006 | ||||||||
| LastUpdateDate: | 08/18/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | PA05622 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 363A00000X | PA05622 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 8389NW | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 208248909 | 05 | TX | MEDICAID | 208248911 | 05 | TX | MEDICAID | 8548NT | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER |