Provider Demographics
NPI:1184759359
Name:PETERSON, GARY C (NP)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:C
Last Name:PETERSON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:482 ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:CO
Mailing Address - Zip Code:80720-1149
Mailing Address - Country:US
Mailing Address - Phone:970-345-2262
Mailing Address - Fax:
Practice Address - Street 1:482 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:CO
Practice Address - Zip Code:80720-1149
Practice Address - Country:US
Practice Address - Phone:970-345-2262
Practice Address - Fax:970-345-2265
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO80231363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO05638457Medicaid
CO80231OtherLICENSE
MP0257419OtherDEA
CO05638457Medicaid