Provider Demographics
NPI:1720004245
Name:PETERIK, MICHAEL D (PA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:D
Last Name:PETERIK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4550 E BELL RD
Mailing Address - Street 2:SUITE 170
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-9306
Mailing Address - Country:US
Mailing Address - Phone:480-443-8400
Mailing Address - Fax:480-443-8697
Practice Address - Street 1:4550 E BELL RD
Practice Address - Street 2:SUITE 170
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-9306
Practice Address - Country:US
Practice Address - Phone:480-443-8400
Practice Address - Fax:480-443-8697
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00155600363A00000X
AZ3397363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJQ63487Medicare UPIN