Provider Demographics
NPI:1033326020
Name:PETERSON, TRAVIS A (DO)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:A
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 W 13490 S STE 100
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-7299
Mailing Address - Country:US
Mailing Address - Phone:801-997-5770
Mailing Address - Fax:435-723-3391
Practice Address - Street 1:61 W 13490 S STE 100
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-7299
Practice Address - Country:US
Practice Address - Phone:801-997-5770
Practice Address - Fax:385-446-6278
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP60232831207X00000X, 207XS0106X
UT10858427-1204207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT10858427-1204OtherLICENSE
WAP00987572OtherRR MEDICARE
WA0282664OtherLABOR & INDUSTRIES
WA2014045Medicaid