Healthcare Provider Details

I. General information

NPI: 1598414096
Provider Name (Legal Business Name): PETER WALMY ST LOUIS ANGERVIL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2022
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1940 MESQUITE AVE
LAKE HAVASU CITY AZ
86403-6123
US

IV. Provider business mailing address

PO BOX 617
SOMERTON AZ
85350-0617
US

V. Phone/Fax

Practice location:
  • Phone: 928-459-3512
  • Fax:
Mailing address:
  • Phone: 928-315-7910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9800
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1238
License Number StatePR
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-253666
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: