Provider Demographics
NPI:1740902410
Name:SEPTEMBRE, PETER BOHAM (TELEHEALTH PROVIDER)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:BOHAM
Last Name:SEPTEMBRE
Suffix:
Gender:M
Credentials:TELEHEALTH PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1858 SW ANGELICO LN
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34984-4457
Mailing Address - Country:US
Mailing Address - Phone:772-722-4907
Mailing Address - Fax:
Practice Address - Street 1:1505 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-3975
Practice Address - Country:US
Practice Address - Phone:772-461-1401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTPPA389363AM0700X
PR001312-P.A.363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical