Healthcare Provider Details

I. General information

NPI: 1417303066
Provider Name (Legal Business Name): PETER PSENDA AGPCNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2016
Last Update Date: 05/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 NORTH AVE
GRAND JUNCTION CO
81501-6428
US

IV. Provider business mailing address

2121 NORTH AVE
GRAND JUNCTION CO
81501-6428
US

V. Phone/Fax

Practice location:
  • Phone: 970-263-6277
  • Fax: 970-248-5595
Mailing address:
  • Phone: 970-263-6277
  • Fax: 970-248-5595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPN0992336
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPN0992336
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: