Provider Demographics
NPI:1306865027
Name:PETERSON, BRIAN K (PT)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:K
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 E. 1140 N. SUITE A
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:UT
Mailing Address - Zip Code:84045
Mailing Address - Country:US
Mailing Address - Phone:801-768-3105
Mailing Address - Fax:801-766-0188
Practice Address - Street 1:41 E. 1140 N. SUITE A
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:UT
Practice Address - Zip Code:84045
Practice Address - Country:US
Practice Address - Phone:801-768-3105
Practice Address - Fax:801-766-0188
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6195947-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1306865027Medicare PIN
UT1811926538Medicare PIN