1841966819 NPI number — RIO PETERSON PMHNP

Table of content: RIO PETERSON PMHNP (NPI 1841966819)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841966819 NPI number — RIO PETERSON PMHNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
RIO
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PMHNP
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:
1841966819
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/28/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
260 BONNER MALL WAY # 1028
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PONDERAY
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83852-9748
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-677-7747
Provider Business Mailing Address Fax Number:
888-849-5240

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4020 GRANITE VIEW ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW MEADOWS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83654
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-677-7747
Provider Business Practice Location Address Fax Number:
888-849-5240
Provider Enumeration Date:
08/19/2021

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: 363LP0808X , with the licence number:  70072 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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