Provider Demographics
NPI:1861472656
Name:PETERSON, SHAUN N (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAUN
Middle Name:N
Last Name:PETERSON
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:PO BOX 31630
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85751-1630
Mailing Address - Country:US
Mailing Address - Phone:520-784-6200
Mailing Address - Fax:520-784-6390
Practice Address - Street 1:5301 E GRANT RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2805
Practice Address - Country:US
Practice Address - Phone:520-784-6200
Practice Address - Fax:520-784-6109
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD10803207X00000X
CAA97027207X00000X
WAMD60145041207X00000X, 207XX0005X
AZ65052207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ100566Medicaid
CA00A970270OtherMEDI-CAL