MEDICARE: ERIC PETERSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WS0200X	School Registered Nurse	RN141586	AZ

General Provider Information

NPI Number	:	1336922715
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIC PETERSON

Provider Business Mailing Address
First Line	:	1001 N POWER RD # 5799
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85205-5701
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1309 N ROCHESTER
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85205-4249
Country	:	US
Telephone Number	:	480-472-8334
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/17/2023
Last Update Date	:	08/17/2023

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Directions to “ ERIC PETERSON ” Practice Location

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