Provider Demographics
NPI:1942891072
Name:STATUE, PETER (PHTC)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:STATUE
Suffix:
Gender:M
Credentials:PHTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 CHRISTINA LN
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08094-3600
Mailing Address - Country:US
Mailing Address - Phone:856-889-8670
Mailing Address - Fax:
Practice Address - Street 1:500 EGG HARBOR RD
Practice Address - Street 2:
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-2336
Practice Address - Country:US
Practice Address - Phone:856-256-7812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RW00820400156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist