Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2080P0203X | Pediatric Critical Care Doctor | 075484 | GA |
N | 2080P0203X | Pediatric Critical Care Doctor | 13205 | ND |
Y | 2080P0203X | Pediatric Critical Care Doctor | 53734 | WI |
NPI | 1154586071 |
---|---|
Provider Name | Jennifer C Peterson |
First Address | La Crosse, WI 54601-5429 |
Second Address | La Crosse, WI 54601-5429 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/07/2008 |
Last Update Date | 07/06/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
81315 | (05) | ND |
PENDING | (05) | GA |