Provider Demographics
NPI:1487844791
Name:PETERS, NICOLAS LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLAS
Middle Name:LEE
Last Name:PETERS
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 1:70 S VAL VISTA DR STE A3-618
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-0942
Mailing Address - Country:US
Mailing Address - Phone:480-485-5166
Mailing Address - Fax:877-991-6652
Practice Address - Street 1:2111 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5600
Practice Address - Country:US
Practice Address - Phone:505-863-1820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.094612208000000X, 2080P0207X
AZ48190208000000X, 2080P0207X, 208M00000X
NMMD2017-0087208M00000X, 208000000X
246QM0706X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0070938Medicaid
OHH146460Medicare PIN