Provider Demographics
NPI:1386949659
Name:PETERSON, RICHARD NICHOLAS (PA)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:NICHOLAS
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1932 S FALCON DR
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-5869
Mailing Address - Country:US
Mailing Address - Phone:480-734-6261
Mailing Address - Fax:
Practice Address - Street 1:1705 E HANNA RD
Practice Address - Street 2:
Practice Address - City:ELOY
Practice Address - State:AZ
Practice Address - Zip Code:85131-9612
Practice Address - Country:US
Practice Address - Phone:520-464-3067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-18
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4680363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical