Provider Demographics
NPI:1912480591
Name:PETERS, RALPH MERRON III (PA-C)
Entity Type:Individual
Prefix:
First Name:RALPH
Middle Name:MERRON
Last Name:PETERS
Suffix:III
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11335 SSG SIMS ST
Mailing Address - Street 2:
Mailing Address - City:FORT BLISS
Mailing Address - State:TX
Mailing Address - Zip Code:79918
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11335 SSG SIMS ST
Practice Address - Street 2:
Practice Address - City:FORT BLISS
Practice Address - State:TX
Practice Address - Zip Code:79918
Practice Address - Country:US
Practice Address - Phone:915-742-1254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
TXPA17854363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical