Provider Demographics
NPI:1083141733
Name:PEGRAM, KELSIE
Entity type:Individual
Prefix:
First Name:KELSIE
Middle Name:
Last Name:PEGRAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:676 FUTENMA
Mailing Address - Street 2:US NAVAL HOSPITAL OKINAWA
Mailing Address - City:GINOWAN
Mailing Address - State:OKINAWA
Mailing Address - Zip Code:9012202
Mailing Address - Country:JP
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:676 FUTENMA
Practice Address - Street 2:NAVAL HOSPITAL OKINAWA
Practice Address - City:GINOWAN
Practice Address - State:OKINAWA
Practice Address - Zip Code:9012202
Practice Address - Country:JP
Practice Address - Phone:898-971-9355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-12
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X
NE30978207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD0000Medicare UPIN