Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 0-261 | ID |
N | 208D00000X | General Practice Physician | 0-261 | ID |
NPI | 1033117205 |
---|---|
Provider Name | Mr. Anthony D Peters |
First Address | Post Falls, ID 83854 |
Second Address | Post Falls, ID 83854 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/07/2005 |
Last Update Date | 02/04/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
806064600 | (05) | ID |
H07834 | (02) |