Provider Demographics
NPI:1598414096
Name:ST LOUIS ANGERVIL, PETER WALMY
Entity Type:Individual
Prefix:
First Name:PETER WALMY
Middle Name:
Last Name:ST LOUIS ANGERVIL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 617
Mailing Address - Street 2:
Mailing Address - City:SOMERTON
Mailing Address - State:AZ
Mailing Address - Zip Code:85350-0617
Mailing Address - Country:US
Mailing Address - Phone:928-315-7932
Mailing Address - Fax:
Practice Address - Street 1:1940 MESQUITE AVE
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6123
Practice Address - Country:US
Practice Address - Phone:928-459-3512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-22
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-253666106S00000X
PR1238207Q00000X
AZ9800363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100588329Medicaid
AZ137583Medicaid