Provider Demographics
NPI:1972337301
Name:PETERSON, CLIFF
Entity type:Individual
Prefix:
First Name:CLIFF
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2999 N 44TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-7247
Mailing Address - Country:US
Mailing Address - Phone:602-795-6400
Mailing Address - Fax:
Practice Address - Street 1:35059 N. 7TH AVE
Practice Address - Street 2:
Practice Address - City:DESERT HILLS
Practice Address - State:AZ
Practice Address - Zip Code:85086
Practice Address - Country:US
Practice Address - Phone:623-445-4948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP038724164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse