Provider Demographics
NPI:1346638939
Name:PETERSEN, GUY ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:GUY
Middle Name:ALAN
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5240 E KNIGHT DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2122
Mailing Address - Country:US
Mailing Address - Phone:520-582-9399
Mailing Address - Fax:
Practice Address - Street 1:5240 E KNIGHT DR
Practice Address - Street 2:SUITE 100
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2122
Practice Address - Country:US
Practice Address - Phone:520-582-9399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ22232208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice