Provider Demographics
NPI:1225119621
Name:PETERSON, BRIAN JARED (PAC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:JARED
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2710 ALPINE BLVD # 434
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:CA
Mailing Address - Zip Code:91901-2276
Mailing Address - Country:US
Mailing Address - Phone:619-326-4445
Mailing Address - Fax:619-722-1721
Practice Address - Street 1:1730 ALPINE BLVD STE 109B
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:CA
Practice Address - Zip Code:91901-3877
Practice Address - Country:US
Practice Address - Phone:619-326-4445
Practice Address - Fax:619-722-1721
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051614207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMA051614OtherSTATE LICENSE
1061442OtherNCCPA
PAMP1103794OtherDEA
PAMP1103794OtherDEA