Provider Demographics
NPI:1255343455
Name:INNES, PETER A (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:A
Last Name:INNES
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:PO BOX 859
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85547-0859
Mailing Address - Country:US
Mailing Address - Phone:928-472-3472
Mailing Address - Fax:928-472-3480
Practice Address - Street 1:603-2 N PROGRESS AVE STE 200
Practice Address - Street 2:
Practice Address - City:SILOAM SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72761-4206
Practice Address - Country:US
Practice Address - Phone:479-215-3040
Practice Address - Fax:479-524-4363
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-28693208600000X
KS01-28693208600000X
AZ43678208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100421520BMedicaid
AZ549477Medicaid
KS100421520DMedicaid
AZ549477Medicaid
AZZ141536Medicare PIN
KS100421520DMedicaid