Provider Demographics
NPI:1417467986
Name:RED LEDGES DERMATOLOGY PLLC
Entity Type:Organization
Organization Name:RED LEDGES DERMATOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:ALBERT
Authorized Official - Last Name:PETERERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:435-703-9296
Mailing Address - Street 1:1449 N 1400 W STE 22
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-5237
Mailing Address - Country:US
Mailing Address - Phone:435-703-9296
Mailing Address - Fax:
Practice Address - Street 1:1449 N 1400 W STE 22
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-5237
Practice Address - Country:US
Practice Address - Phone:435-703-9296
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-10
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT179077-1204207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty