Healthcare Provider Details

I. General information

NPI: 1750472023
Provider Name (Legal Business Name): PETER RUNICH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 FULTON ST.
DURHAM NC
27705
US

IV. Provider business mailing address

302 SANDLEWOOD DR.
DURHAM NC
27712
US

V. Phone/Fax

Practice location:
  • Phone: 919-286-0411
  • Fax: 919-416-5857
Mailing address:
  • Phone: 919-471-8172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: