Provider Demographics
NPI:1255491478
Name:PETERSON, GARY (PT)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1752 E BULLARD AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-5864
Mailing Address - Country:US
Mailing Address - Phone:559-438-0355
Mailing Address - Fax:559-438-0359
Practice Address - Street 1:1702 E BULLARD AVE STE 103
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-5800
Practice Address - Country:US
Practice Address - Phone:559-438-0355
Practice Address - Fax:559-438-0359
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32604225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ26802ZMedicare UPIN