Provider Demographics
NPI:1093252439
Name:PETERS, RUSSELL ALLEN (APRN)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:ALLEN
Last Name:PETERS
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 1:1190 RYNES RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TN
Mailing Address - Zip Code:37322-7420
Mailing Address - Country:US
Mailing Address - Phone:423-718-8134
Mailing Address - Fax:
Practice Address - Street 1:138 S. MAIN ST
Practice Address - Street 2:
Practice Address - City:AFTON
Practice Address - State:OK
Practice Address - Zip Code:74331
Practice Address - Country:US
Practice Address - Phone:918-257-8029
Practice Address - Fax:918-257-8042
Is Sole Proprietor?:No
Enumeration Date:2017-01-24
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000020958363LF0000X
OK0123709363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily