Provider Demographics
NPI:1093458044
Name:PETERSON, KEYAN A
Entity Type:Individual
Prefix:
First Name:KEYAN
Middle Name:A
Last Name:PETERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 BENJAMIN RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:NC
Mailing Address - Zip Code:27025-2257
Mailing Address - Country:US
Mailing Address - Phone:336-708-7198
Mailing Address - Fax:
Practice Address - Street 1:1211 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37232-0004
Practice Address - Country:US
Practice Address - Phone:615-322-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program