Doctor Name: | KEITH E PETERSEN |
NPI Number: | 1356615470 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | DO |
License Number: | 1078 |
Business Practice Address: | 9040 Fitzsimmons Dr Joint Base Lewis Mcchord, WA - 984311000 |
Business Phone Number: | 2539681340 |
Business Fax Number: | |
Mailing Address: | 9040 Fitzsimmons Dr, JOINT BASE LEWIS MCCHORD |
State: | WA |
Postal Code: | 984311000 |
Phone Number: | 2539681340 |
Fax Number: | |
NPI Enumeration Date: | 03/07/2012 |
NPI Last Update Date: | 09/12/2013 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 208D00000X |
License Number: | 1078 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | NE |
Taxonomy Type: | Allopathic & Osteopathic Physicians |
Taxonomy Classification: | General Practice |
Taxonomy Specialization: | |
Taxonomy Definition: |