Provider Demographics
NPI:1326252149
Name:PETERS, GREGORY TYRONE (MPT)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:TYRONE
Last Name:PETERS
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:877 MCRAE AVE
Mailing Address - Street 2:
Mailing Address - City:WADESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28170-6491
Mailing Address - Country:US
Mailing Address - Phone:704-694-9604
Mailing Address - Fax:
Practice Address - Street 1:877 MCRAE AVE
Practice Address - Street 2:
Practice Address - City:WADESBORO
Practice Address - State:NC
Practice Address - Zip Code:28170-6491
Practice Address - Country:US
Practice Address - Phone:704-694-9604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20679225100000X
NCP11670225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist