Provider Demographics
NPI:1003352683
Name:RAISANEN, PETER KONSTANTINE (NMD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:KONSTANTINE
Last Name:RAISANEN
Suffix:
Gender:M
Credentials:NMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10444 N 69TH ST # 101
Mailing Address - Street 2:
Mailing Address - City:PARADISE VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85253-1452
Mailing Address - Country:US
Mailing Address - Phone:480-256-2436
Mailing Address - Fax:833-986-0103
Practice Address - Street 1:10444 N 69TH ST APT 101
Practice Address - Street 2:
Practice Address - City:PARADISE VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85253-1453
Practice Address - Country:US
Practice Address - Phone:480-256-2436
Practice Address - Fax:833-986-0103
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-06
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17-1688175F00000X
CAND865175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath