1962257949 NPI number — MR. TRAVIS ANTHONY PETERSEN BA, MFA

Table of content: MR. TRAVIS ANTHONY PETERSEN BA, MFA (NPI 1962257949)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962257949 NPI number — MR. TRAVIS ANTHONY PETERSEN BA, MFA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSEN
Provider First Name:
TRAVIS
Provider Middle Name:
ANTHONY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
BA, MFA
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:
1962257949
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/22/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3305 W MAYFLOWER WAY STE 4
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEHI
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84043-2961
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
833-208-9009
Provider Business Mailing Address Fax Number:
866-680-1322

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3305 W MAYFLOWER WAY STE 4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEHI
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84043-2961
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
833-208-9009
Provider Business Practice Location Address Fax Number:
866-680-1322
Provider Enumeration Date:
04/22/2024

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: 156FX1700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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