Provider Demographics
NPI:1902358922
Name:POMMERVILLE, PETER JOHN (BA, MD, FRCSC)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:JOHN
Last Name:POMMERVILLE
Suffix:
Gender:M
Credentials:BA, MD, FRCSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 PALE SAN VITORES ROAD
Mailing Address - Street 2:
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96913
Mailing Address - Country:US
Mailing Address - Phone:671-647-4542
Mailing Address - Fax:671-647-4558
Practice Address - Street 1:280 PALE SAN VITORES ROAD
Practice Address - Street 2:
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913
Practice Address - Country:US
Practice Address - Phone:671-647-4542
Practice Address - Fax:671-647-4558
Is Sole Proprietor?:No
Enumeration Date:2016-10-25
Last Update Date:2022-07-21
Deactivation Date:2017-05-31
Deactivation Code:
Reactivation Date:2017-07-12
Provider Licenses
StateLicense IDTaxonomies
GUM-19552088F0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2088F0040XAllopathic & Osteopathic PhysiciansUrologyFemale Pelvic Medicine and Reconstructive Surgery