Provider Demographics
NPI:1245525930
Name:PETERSEN, NATHAN JEFFREY (MD)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:JEFFREY
Last Name:PETERSEN
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 1:6370 W UNION HILLS DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-7136
Mailing Address - Country:US
Mailing Address - Phone:623-414-3500
Mailing Address - Fax:623-455-9214
Practice Address - Street 1:6370 W UNION HILLS DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7136
Practice Address - Country:US
Practice Address - Phone:623-414-3500
Practice Address - Fax:623-455-9214
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-10
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR72843207V00000X
AZ51043207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ167288Medicaid