Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 016040-1 | NY |
NPI | 1003062001 |
---|---|
Provider Name | Mr. Michael Carl Peterson |
First Address | Jamestown, NY 14701-8906 |
Second Address | Jamestown, NY 14701-8906 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/08/2008 |
Last Update Date | 07/01/2010 |