Healthcare Provider Details

I. General information

NPI: 1902358922
Provider Name (Legal Business Name): PETER JOHN POMMERVILLE BA, MD, FRCSC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2016
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date: 05/31/2017
Reactivation Date: 07/12/2017

III. Provider practice location address

280 PALE SAN VITORES ROAD
TAMUNING GU
96913
US

IV. Provider business mailing address

280 PALE SAN VITORES ROAD
TAMUNING GU
96913
US

V. Phone/Fax

Practice location:
  • Phone: 671-647-4542
  • Fax: 671-647-4558
Mailing address:
  • Phone: 671-647-4542
  • Fax: 671-647-4558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088F0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Urology) Physician
License NumberM-1955
License Number StateGU

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: