Provider Demographics
NPI:1477607083
Name:PETERSEN, MATTHEW D (ST)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:D
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:ST
Other - Prefix:
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Mailing Address - Street 1:20 ELMWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-1623
Mailing Address - Country:US
Mailing Address - Phone:712-256-7953
Mailing Address - Fax:
Practice Address - Street 1:11704 W CENTER RD STE 200
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-4327
Practice Address - Country:US
Practice Address - Phone:402-691-0500
Practice Address - Fax:402-691-1586
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist