Provider Demographics
NPI:1598434664
Name:PETERSON, GARY
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:PETERSON
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 1:3276 OLD HARRISBURG RD
Mailing Address - Street 2:
Mailing Address - City:GETTYSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17325-7543
Mailing Address - Country:US
Mailing Address - Phone:717-334-9736
Mailing Address - Fax:
Practice Address - Street 1:3276 OLD HARRISBURG RD
Practice Address - Street 2:
Practice Address - City:GETTYSBURG
Practice Address - State:PA
Practice Address - Zip Code:17325-7543
Practice Address - Country:US
Practice Address - Phone:717-334-9736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-10
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker