Healthcare Provider Details

I. General information

NPI: 1629147731
Provider Name (Legal Business Name): GARY PETERSON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 02/25/2026
Certification Date: 02/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31515 RANCHO PUEBLO RD STE 201
TEMECULA CA
92592-4837
US

IV. Provider business mailing address

PO BOX 2123
VALLEY CENTER CA
92082-2123
US

V. Phone/Fax

Practice location:
  • Phone: 951-302-1302
  • Fax: 760-239-6893
Mailing address:
  • Phone: 760-571-7015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 16479
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: