Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 2065 | AZ |
NPI | 1003921800 |
---|---|
Provider Name | Terry K Peterson |
First Address | Mesa, AZ 85206-1700 |
Second Address | Mesa, AZ 85206-1700 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/08/2006 |
Last Update Date | 23/04/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U06111 | (02) | AZ |