Provider Demographics
NPI:1104540392
Name:PETERS, MARK (APRN)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:PETERS
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11414 BLUFFS RDG
Mailing Address - Street 2:
Mailing Address - City:SPOTSYLVANIA
Mailing Address - State:VA
Mailing Address - Zip Code:22551-8915
Mailing Address - Country:US
Mailing Address - Phone:646-346-0834
Mailing Address - Fax:
Practice Address - Street 1:3031 WILLIAMS RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-5633
Practice Address - Country:US
Practice Address - Phone:706-221-7139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-30
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11020587363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics