Provider Demographics
NPI:1922784628
Name:PETERSON, GWENDOLYN ARNETT
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:ARNETT
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 ROADRUNNER DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ELM
Mailing Address - State:TX
Mailing Address - Zip Code:75068-8543
Mailing Address - Country:US
Mailing Address - Phone:214-810-1815
Mailing Address - Fax:
Practice Address - Street 1:1009 ROADRUNNER DR
Practice Address - Street 2:
Practice Address - City:LITTLE ELM
Practice Address - State:TX
Practice Address - Zip Code:75068-8543
Practice Address - Country:US
Practice Address - Phone:214-810-1815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies