Provider Demographics
NPI:1407925209
Name:PETERS, REGINALD R (PA)
Entity Type:Individual
Prefix:MR
First Name:REGINALD
Middle Name:R
Last Name:PETERS
Suffix:
Gender:M
Credentials:PA
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Other - Credentials:
Mailing Address - Street 1:4065 COUNTY CIRCLE DR
Mailing Address - Street 2:ROOM 309
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-3410
Mailing Address - Country:US
Mailing Address - Phone:951-358-5222
Mailing Address - Fax:951-358-5235
Practice Address - Street 1:2499 E LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-4411
Practice Address - Country:US
Practice Address - Phone:951-471-4200
Practice Address - Fax:951-471-4205
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA18227363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMP1415101OtherDEA