Basic Information
| Provider Information | |||||||||
| NPI: | 1982716585 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TALLENT | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | DERRICK | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 BLUE RIDGE RD STE 417 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276077516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197879097 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4420 LAKE BOONE TRL | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276077505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197843100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 11/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 021664 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 1020 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 001000359 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 0010-00359 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | GP1062 | 05 | SC | MEDICAID | 02914 | 01 | NC | NC BCBS | OTHER | 1020 | 01 | SC | MEDICAL LICENSE | OTHER | 8902914 | 05 | NC | MEDICAID | CM7718 | 01 | RAILROAD MEDICARE | OTHER |