Provider Demographics
NPI:1164069696
Name:PETERSON, MARK ALAN (EDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5870 NW 54TH CT
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON
Mailing Address - State:IA
Mailing Address - Zip Code:50131-1418
Mailing Address - Country:US
Mailing Address - Phone:515-462-4367
Mailing Address - Fax:
Practice Address - Street 1:5870 NW 54TH CT
Practice Address - Street 2:
Practice Address - City:JOHNSTON
Practice Address - State:IA
Practice Address - Zip Code:50131-1418
Practice Address - Country:US
Practice Address - Phone:515-462-4367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-03
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care