Individual
CAROLYN G PETERSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
P.A. - C
Contact information
Practice address
5779 E MAYO BLVD, PHOENIX, AZ 85054-4502
(480) 301-8000
Mailing address
5779 E MAYO BLVD, PHOENIX, AZ 85054-4502
(480) 301-8000
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
1874
AZ
363AS0400X
Surgical Physician Assistant
1874
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
240004028
RAILROAD MEDICARE
AZ
05
—
344458
—
AZ
01
—
86080015085259A199
TRIWEST
AZ
Enumeration date
11/16/2005
Last updated
02/11/2021
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