Provider Demographics
NPI:1063642510
Name:PETERSON, CLINT W (APRN)
Entity Type:Individual
Prefix:
First Name:CLINT
Middle Name:W
Last Name:PETERSON
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 S 400 W
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:UT
Mailing Address - Zip Code:84651-2702
Mailing Address - Country:US
Mailing Address - Phone:801-234-9543
Mailing Address - Fax:
Practice Address - Street 1:750 N 200 W
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1677
Practice Address - Country:US
Practice Address - Phone:801-373-9656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-17
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5938005-3102163W00000X
UT5938005-4408363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse