1952444101 NPI number — AIMEE CATHERINE PETERSON OTRL

Table of content: AIMEE CATHERINE PETERSON OTRL (NPI 1952444101)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952444101 NPI number — AIMEE CATHERINE PETERSON OTRL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
AIMEE
Provider Middle Name:
CATHERINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTRL
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:
1952444101
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/03/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19114 KANAWHA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORNELIUS
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28031-9394
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-451-0660
Provider Business Mailing Address Fax Number:
980-206-0111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19114 KANAWHA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORNELIUS
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28031-9394
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
832-451-0660
Provider Business Practice Location Address Fax Number:
980-206-0111
Provider Enumeration Date:
02/15/2007

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: 225X00000X , with the licence number:  102825 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X , with the licence number: 3388 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1952444101 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 055588600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 961S7KE . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP42429 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 6403492 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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