Provider Demographics
NPI:1902819550
Name:TIERNAN, PETER KING JR (MD,MPH, LTC USAFR)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:KING
Last Name:TIERNAN
Suffix:JR
Gender:M
Credentials:MD,MPH, LTC USAFR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7920 CARMEL AVE NE STE C
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-2967
Mailing Address - Country:US
Mailing Address - Phone:505-344-4959
Mailing Address - Fax:
Practice Address - Street 1:7920 CARMEL AVE NE STE C
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87122-2967
Practice Address - Country:US
Practice Address - Phone:505-344-4959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2006-0119208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G834610Medicare ID - Type Unspecified
CAG08064Medicare UPIN