MEDICARE: GWENDOLYN ARNETT 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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1922784628
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GWENDOLYN ARNETT PETERSON

Provider Business Mailing Address
First Line	:	1009 ROADRUNNER DR
Second Line	:
City	:	LITTLE ELM
State	:	TX
Zip	:	75068-8543
Country	:	US
Telephone Number	:	214-810-1815
Fax Number	:

Provider Business Practice Location Address
First Line	:	1009 ROADRUNNER DR
Second Line	:
City	:	LITTLE ELM
State	:	TX
Zip	:	75068-8543
Country	:	US
Telephone Number	:	214-810-1815
Fax Number	:

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

Provider Enumeration Date	:	06/26/2023
Last Update Date	:	06/26/2023

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