Healthcare Provider Details

I. General information

NPI: 1407598428
Provider Name (Legal Business Name): NICHOLAS PATRICK PETERS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2022
Last Update Date: 12/18/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4949 PROFESSIONAL PARK DR STE 101
KANNAPOLIS NC
28081-8637
US

IV. Provider business mailing address

PO BOX 19305
CHARLOTTE NC
28219-9305
US

V. Phone/Fax

Practice location:
  • Phone: 704-938-6521
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-12604
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: