Provider Demographics
NPI:1154580629
Name:PERALTA, ROSA MARIA (FNP)
Entity type:Individual
Prefix:
First Name:ROSA
Middle Name:MARIA
Last Name:PERALTA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1368
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85366-1368
Mailing Address - Country:US
Mailing Address - Phone:760-572-4105
Mailing Address - Fax:760-572-2133
Practice Address - Street 1:401 PICACHO ROAD
Practice Address - Street 2:
Practice Address - City:WINTERHAVEN
Practice Address - State:CA
Practice Address - Zip Code:92283
Practice Address - Country:US
Practice Address - Phone:760-572-4100
Practice Address - Fax:760-572-2113
Is Sole Proprietor?:No
Enumeration Date:2008-06-09
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP17863363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8HH866OtherINDIV PROV B
AZ020511Medicaid
AZ020511Medicaid
CA8HH866OtherINDIV PROV B