Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251X0800X | Physical Therapist - Orthopedic | 2390-24 | WI |
NPI | 1063434884 |
---|---|
Provider Name | Matthew D Peterson |
First Address | Middleton, WI 53562-3036 |
Second Address | Middleton, WI 53562-3036 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/07/2006 |
Last Update Date | 22/03/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2390-24 | PT ORTHOPEDICS (01) | WI |