Provider Demographics
NPI:1649289653
Name:PETERMAN, GERALD (NP)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:
Last Name:PETERMAN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 HERITAGE DR
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31093-6621
Mailing Address - Country:US
Mailing Address - Phone:478-922-7954
Mailing Address - Fax:
Practice Address - Street 1:2054 WATSON BLVD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-3634
Practice Address - Country:US
Practice Address - Phone:478-633-2097
Practice Address - Fax:478-633-7836
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN122988363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA498794628BMedicaid
GA50BBJSFMedicare ID - Type Unspecified
GA498794628BMedicaid