Doctor Name: | WALTER RAY PETERSEN |
NPI Number: | 1164711586 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | M.D. |
License Number: | M2705 |
Business Practice Address: | 1344 Hiland Ave Burley, ID - 833181564 |
Business Phone Number: | 2086781138 |
Business Fax Number: | |
Mailing Address: | 1344 Hiland Ave, BURLEY |
State: | ID |
Postal Code: | 833181564 |
Phone Number: | 2086781138 |
Fax Number: | |
NPI Enumeration Date: | 04/06/2011 |
NPI Last Update Date: | 04/06/2011 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 208D00000X |
License Number: | M2705 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | ID |
Taxonomy Type: | Allopathic & Osteopathic Physicians |
Taxonomy Classification: | General Practice |
Taxonomy Specialization: | |
Taxonomy Definition: |