Provider Demographics
NPI:1003058579
Name:PETERSEN, ASHLEY ANNE (MD)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:ANNE
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:ANNE
Other - Last Name:GEDDIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6600 S YALE AVE
Mailing Address - Street 2:SUITE 1400
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3347
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30011 E STATE HIGHWAY 51
Practice Address - Street 2:
Practice Address - City:COWETA
Practice Address - State:OK
Practice Address - Zip Code:74429-7681
Practice Address - Country:US
Practice Address - Phone:918-486-2161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-30
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OK29052208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program