Provider Demographics
NPI:1073078275
Name:PETERSON, ELYSIA (PT)
Entity Type:Individual
Prefix:
First Name:ELYSIA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11470 BUSINESS BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-7780
Mailing Address - Country:US
Mailing Address - Phone:907-696-5678
Mailing Address - Fax:907-696-2248
Practice Address - Street 1:11470 BUSINESS BLVD STE 200
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7780
Practice Address - Country:US
Practice Address - Phone:907-696-5678
Practice Address - Fax:907-696-2248
Is Sole Proprietor?:No
Enumeration Date:2019-02-01
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT6597225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist