Individual
GREGORY DERRICK TALLENT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PAC
Contact information
Practice address
4420 LAKE BOONE TRL, RALEIGH, NC 27607-7505
(919) 784-3100
Mailing address
2500 BLUE RIDGE RD STE 417, RALEIGH, NC 27607-7516
(919) 787-9097
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
0010-00359
NC
363A00000X
Physician Assistant
021664
NY
363AM0700X
Medical Physician Assistant
001000359
NC
363AM0700X
Medical Physician Assistant
1020
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
02914
NC BCBS
NC
01
—
1020
MEDICAL LICENSE
SC
05
—
8902914
—
NC
01
—
CM7718
RAILROAD MEDICARE
—
05
—
GP1062
—
SC
Enumeration date
08/31/2006
Last updated
11/23/2021
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