Provider Demographics
NPI:1821562885
Name:PETERSON, STEPHEN LYNN II
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:LYNN
Last Name:PETERSON
Suffix:II
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 1:1350 S ELLSWORTH RD APT 1122
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-2809
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1350 S ELLSWORTH RD APT 1122
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-2809
Practice Address - Country:US
Practice Address - Phone:480-326-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-13
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1945208332B00000X
AZ005988227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ480036OtherAHCCCS