MEDICARE: PETER WALMY ST LOUIS ANGERVIL

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	106S00000X	Behavior Technician	RBT-23-253666	FL
2	207Q00000X	Family Medicine Physician	1238	PR
3	363A00000X	Physician Assistant	9800	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598414096
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETER WALMY ST LOUIS ANGERVIL

Provider Business Mailing Address
First Line	:	PO BOX 617
Second Line	:
City	:	SOMERTON
State	:	AZ
Zip	:	85350-0617
Country	:	US
Telephone Number	:	928-315-7910
Fax Number	:

Provider Business Practice Location Address
First Line	:	1940 MESQUITE AVE
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-6123
Country	:	US
Telephone Number	:	928-459-3512
Fax Number	:

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

Provider Enumeration Date	:	03/22/2022
Last Update Date	:	08/13/2024

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Directions to “ PETER WALMY ST LOUIS ANGERVIL ” Practice Location

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