Provider Demographics
NPI:1134110893
Name:PEREGRINE, ROBERTA J
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:J
Last Name:PEREGRINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2602 FREDERICK AVE
Mailing Address - Street 2:STE A
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-2847
Mailing Address - Country:US
Mailing Address - Phone:816-387-8858
Mailing Address - Fax:816-387-8858
Practice Address - Street 1:2602 FREDERICK AVE
Practice Address - Street 2:STE A
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-2840
Practice Address - Country:US
Practice Address - Phone:816-387-8858
Practice Address - Fax:816-387-8858
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO27826022OtherBLUECROSSBLUESHIELD
MO3852580001Medicare NSC