1023227238 NPI number — DR. COLLEEN MARGARET PETERSON PH.D.

Table of content: DR. COLLEEN MARGARET PETERSON PH.D. (NPI 1023227238)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023227238 NPI number — DR. COLLEEN MARGARET PETERSON PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
COLLEEN
Provider Middle Name:
MARGARET
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

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:
1023227238
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:
1796 BAJA LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HENDERSON
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89012-3108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-269-5781
Provider Business Mailing Address Fax Number:
702-895-4797

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4505 S MARYLAND PKWY
Provider Second Line Business Practice Location Address:
BOX 453047
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89154-9900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-895-4798
Provider Business Practice Location Address Fax Number:
702-895-4797
Provider Enumeration Date:
05/22/2007

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: 106H00000X , with the licence number:  0850 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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