Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207X00000X | Orthopaedic Surgeon | OP60232831 | WA |
N | 207XS0106X | Orthopaedic Hand Surgeon | OP60232831 | WA |
NPI | 1033326020 |
---|---|
Provider Name | Travis A Peterson |
First Address | Brigham City, UT 84302-3077 |
Second Address | Brigham City, UT 84302-3077 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/05/2007 |
Last Update Date | 12/09/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0282664 | LABOR & INDUSTRIES (01) | WA |
2014045 | (05) | WA |
P00987572 | RR MEDICARE (01) | WA |