Provider Demographics
NPI:1861705014
Name:PETTERSON, GARY ALAN (PT)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:ALAN
Last Name:PETTERSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5216 W SWEETWATER AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85304-1313
Mailing Address - Country:US
Mailing Address - Phone:602-938-8782
Mailing Address - Fax:
Practice Address - Street 1:17225 N BOSWELL BLVD
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85373-2080
Practice Address - Country:US
Practice Address - Phone:623-933-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-16
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1417225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist