Provider Demographics
NPI:1538673181
Name:PETERSON, THOMAS (DNP)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 255228
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95865-5228
Mailing Address - Country:US
Mailing Address - Phone:916-708-8038
Mailing Address - Fax:
Practice Address - Street 1:16911 WILLOW GLEN RD.
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95919
Practice Address - Country:US
Practice Address - Phone:530-675-0466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-18
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP35008779207Q00000X
TXF11170360207Q00000X
CA95008779207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine