Provider Demographics
NPI:1417382664
Name:PETERSON, JOHN A (RN, ACNP BC (APRN))
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:A
Last Name:PETERSON
Suffix:
Gender:M
Credentials:RN, ACNP BC (APRN)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 STICKLAND
Mailing Address - Street 2:SUITE 320
Mailing Address - City:ORANGE
Mailing Address - State:TX
Mailing Address - Zip Code:77630
Mailing Address - Country:US
Mailing Address - Phone:409-883-5300
Mailing Address - Fax:409-883-5394
Practice Address - Street 1:610 STICKLAND
Practice Address - Street 2:SUITE 320
Practice Address - City:ORANGE
Practice Address - State:TX
Practice Address - Zip Code:77611
Practice Address - Country:US
Practice Address - Phone:409-883-5300
Practice Address - Fax:409-883-5394
Is Sole Proprietor?:No
Enumeration Date:2013-09-06
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX596368363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner