Provider Demographics
NPI:1871654418
Name:PETERSON, ALICE RUTH (PA-C)
Entity type:Individual
Prefix:MISS
First Name:ALICE
Middle Name:RUTH
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 33269
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85067-3269
Mailing Address - Country:US
Mailing Address - Phone:602-406-4786
Mailing Address - Fax:916-636-4358
Practice Address - Street 1:4545 E CHANDLER BLVD STE 104
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-7647
Practice Address - Country:US
Practice Address - Phone:480-728-4400
Practice Address - Fax:480-728-4411
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ2837363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZMP0991871OtherDEA