Provider Demographics
NPI:1245220086
Name:PETERSON, RON (FNP)
Entity Type:Individual
Prefix:
First Name:RON
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 CARSON AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LA JUNTA
Mailing Address - State:CO
Mailing Address - Zip Code:81050-2751
Mailing Address - Country:US
Mailing Address - Phone:719-383-5900
Mailing Address - Fax:719-383-6533
Practice Address - Street 1:1100 CARSON AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:LA JUNTA
Practice Address - State:CO
Practice Address - Zip Code:81050-2751
Practice Address - Country:US
Practice Address - Phone:719-383-5900
Practice Address - Fax:719-383-6533
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO55424363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO840706945002OtherROCKY MOUNTAIN HEALTH PLA
471898Medicare ID - Type Unspecified
S74542Medicare UPIN