Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207P00000X | Emergency Physician | WI26696 | WI |
N | 207PE0004X | Emergency Medical Services | WI26696 | WI |
N | 207PP0204X | Pediatric Emergency Physician | WI26696 | WI |
NPI | 1609820620 |
---|---|
Provider Name | Thomas L Peterson |
First Address | Marshfield, WI 54449-5703 |
Second Address | Rice Lake, WI 54868-5000 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/05/2006 |
Last Update Date | 15/02/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
30653800 | (05) | WI |
B55719 | (02) |