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General NPI Number Information
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NPI Number | 1932364924
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Entity Type | Individual
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Provider Name | GARY LAVERN PETERSON JR. DO
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Gender | Male
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Dates
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Enumeration Date | 07/19/2008
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Last Update Date | 05/31/2023
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Provider Practice Location Address
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Address Line | 5637 PEACH ST
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City | ERIE
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State | PA
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Zip | 16509-2605
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Country | US
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Telephone | 814-864-0690
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Fax | 814-866-5147
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Provider Business Mailing Address
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Address Line | 1 LECOM PL
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City | ERIE
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State | PA
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Zip | 16505-2571
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Country | US
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Telephone |
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Fax | 814-868-2522
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | OS015170
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License Number State | PA
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