Healthcare Provider Details

I. General information

NPI: 1487844791
Provider Name (Legal Business Name): NICOLAS LEE PETERS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2007
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2204 S DOBSON RD STE 102
MESA AZ
85202-6457
US

IV. Provider business mailing address

70 S VAL VISTA DR STE A3-618
GILBERT AZ
85296-1374
US

V. Phone/Fax

Practice location:
  • Phone: 480-485-5166
  • Fax: 877-991-6652
Mailing address:
  • Phone: 480-485-5166
  • Fax: 877-991-6652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number48190
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.094612
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD2017-0087
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number48190
License Number StateAZ
# 5
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number35.094612
License Number StateOH
# 6
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number48190
License Number StateAZ
# 7
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD2017-0087
License Number StateNM
# 8
Primary TaxonomyN
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: