Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0505X | Family Doctor - Adult Medicine | 3714 | AZ |
NPI | 1225167281 |
---|---|
Provider Name | Dr. Gregory Wayne Petersburg |
First Address | Oro Valley, AZ 85737-9392 |
Second Address | Oro Valley, AZ 85737-9392 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/03/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
3714 | AZ MEDICAL LICENSE (01) | AZ |
E27270 | (02) | AZ |