1548317175 NPI number — MR. ROBERT CLAYTON PETERMAN DOM, LMT, LAC

Table of content: MR. ROBERT CLAYTON PETERMAN DOM, LMT, LAC (NPI 1548317175)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548317175 NPI number — MR. ROBERT CLAYTON PETERMAN DOM, LMT, LAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERMAN
Provider First Name:
ROBERT
Provider Middle Name:
CLAYTON
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
DOM, LMT, LAC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548317175
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2172
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CODY
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82414-2172
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-587-5951
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1907 BECK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CODY
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82414-3928
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-587-5951
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  DOM 775 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 171100000X , with the licence number: AK000703 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 225700000X , with the licence number: 4307 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 314457 . This is a "BLUE CROSS OF WYOMING" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".




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