Provider Demographics
NPI:1396361119
Name:PETERSON, JOHN KENDALL JR (RRT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:KENDALL
Last Name:PETERSON
Suffix:JR
Gender:M
Credentials:RRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 OLD COLONY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH ABINGTON TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:18411-1604
Mailing Address - Country:US
Mailing Address - Phone:570-357-6956
Mailing Address - Fax:570-586-2910
Practice Address - Street 1:522 OLD COLONY RD
Practice Address - Street 2:
Practice Address - City:SOUTH ABINGTON TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:18411-1604
Practice Address - Country:US
Practice Address - Phone:570-357-6956
Practice Address - Fax:570-586-2910
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-17
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAYM004617L227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredGroup - Single Specialty