Healthcare Provider Details

I. General information

NPI: 1760702989
Provider Name (Legal Business Name): JUDITH E PETO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2010
Last Update Date: 06/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 NEWHALL ST
SAN JOSE CA
95126-1032
US

IV. Provider business mailing address

902 NEWHALL ST
SAN JOSE CA
95126-1032
US

V. Phone/Fax

Practice location:
  • Phone: 408-249-6760
  • Fax: 408-249-6764
Mailing address:
  • Phone: 408-249-6760
  • Fax: 408-249-6764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA19689
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: