Provider Demographics
NPI:1053459867
Name:PETERSON, NATHAN RANDALL (DO)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:RANDALL
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 1:573 TARKILN OAK CIR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32506-9677
Mailing Address - Country:US
Mailing Address - Phone:850-492-6381
Mailing Address - Fax:
Practice Address - Street 1:SANTA MARGARITA
Practice Address - Street 2:
Practice Address - City:CAMP PENLETON
Practice Address - State:CA
Practice Address - Zip Code:92055
Practice Address - Country:US
Practice Address - Phone:760-725-1288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ39020000X390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program