Provider Demographics
NPI:1265213375
Name:PETERS, COSETTE
Entity type:Individual
Prefix:
First Name:COSETTE
Middle Name:
Last Name:PETERS
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 1:3620 WOODSIDE TER
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94539-8048
Mailing Address - Country:US
Mailing Address - Phone:510-552-0323
Mailing Address - Fax:
Practice Address - Street 1:3130 DEL MONTE BLVD
Practice Address - Street 2:
Practice Address - City:MARINA
Practice Address - State:CA
Practice Address - Zip Code:93933-3047
Practice Address - Country:US
Practice Address - Phone:831-883-3330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-13
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA63146363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant