Healthcare Provider Details

I. General information

NPI: 1336964022
Provider Name (Legal Business Name): PETER DUONG PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2024
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4135 S POWER RD STE 129
MESA AZ
85212-3627
US

IV. Provider business mailing address

4135 S POWER RD STE 129
MESA AZ
85212-3627
US

V. Phone/Fax

Practice location:
  • Phone: 480-751-3091
  • Fax: 480-840-9320
Mailing address:
  • Phone: 480-751-3091
  • Fax: 480-840-9320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10938
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: