Provider Demographics
NPI:1164963278
Name:PETERSEN, TRAVIS (BOCP, COA)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:BOCP, COA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 JOHNS HOPKINS DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-7268
Mailing Address - Country:US
Mailing Address - Phone:252-752-7422
Mailing Address - Fax:252-752-5424
Practice Address - Street 1:835 JOHNS HOPKINS DR
Practice Address - Street 2:SUITE B
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-7268
Practice Address - Country:US
Practice Address - Phone:252-752-7422
Practice Address - Fax:252-752-5424
Is Sole Proprietor?:No
Enumeration Date:2017-03-09
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
C52140224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist