Healthcare Provider Details

I. General information

NPI: 1407074024
Provider Name (Legal Business Name): SANDRA M. PETERSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13400 E SHEA BLVD
SCOTTSDALE AZ
85259-5404
US

IV. Provider business mailing address

11820 N 91ST PL
SCOTTSDALE AZ
85260-6869
US

V. Phone/Fax

Practice location:
  • Phone: 480-301-7650
  • Fax: 480-301-9008
Mailing address:
  • Phone: 480-860-6004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835X0200X
TaxonomyOncology Pharmacist
License Number8564
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: