Healthcare Provider Details

I. General information

NPI: 1972337301
Provider Name (Legal Business Name): CLIFF PETERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 08/28/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35059 N. 7TH AVE
DESERT HILLS AZ
85086
US

IV. Provider business mailing address

2999 N 44TH ST STE 100
PHOENIX AZ
85018-7247
US

V. Phone/Fax

Practice location:
  • Phone: 623-445-4948
  • Fax:
Mailing address:
  • Phone: 602-795-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLP038724
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: