Individual
GARY LAVERN PETERSON JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
5637 PEACH ST, ERIE, PA 16509-2605
(814) 864-0690
(814) 866-5147
Mailing address
1 LECOM PL, ERIE, PA 16505-2571
(814) 868-2522
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
OS015170
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1024750790001
—
PA
05
—
1024750790002
—
PA
Enumeration date
07/19/2008
Last updated
05/31/2023
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