| Doctor Name: | TY PETERSON |
| NPI Number: | 1225406226 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | D.P.T. |
| License Number: | 30355 |
| Business Practice Address: | 3801 E Highway 98 Port St Joe, FL - 324565318 |
| Business Phone Number: | 8502295600 |
| Business Fax Number: | |
| Mailing Address: | 3116 E 3rd St, PANAMA CITY |
| State: | FL |
| Postal Code: | 324015643 |
| Phone Number: | |
| Fax Number: | |
| NPI Enumeration Date: | 09/08/2015 |
| NPI Last Update Date: | 09/08/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 2251X0800X |
| License Number: | 30355 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | FL |
| Taxonomy Type: | Respiratory, Developmental, Rehabilitative and Restorative Service Providers |
| Taxonomy Classification: | Physical Therapist |
| Taxonomy Specialization: | Orthopedic |
| Taxonomy Definition: | |