Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | 49636 | CA |
Y | 213EG0000X | General Practice | 49636 | CA |
NPI | 1003052606 |
---|---|
Provider Name | Flaviane Petersen |
First Address | Roseville, CA 95661-4602 |
Second Address | Roseville, CA 95661-4602 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/01/2009 |
Last Update Date | 02/01/2009 |