Healthcare Provider Details

I. General information

NPI: 1770511008
Provider Name (Legal Business Name): RALPH G PETERSON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 03/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 OAK ST SUITE 200
EUGENE OR
97401-4604
US

IV. Provider business mailing address

1410 OAK ST SUITE 200
EUGENE OR
97401-4604
US

V. Phone/Fax

Practice location:
  • Phone: 541-485-2357
  • Fax: 541-485-2358
Mailing address:
  • Phone: 541-485-2357
  • Fax: 541-485-2358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA00258
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: