Provider Demographics
NPI:1548790868
Name:PETERSON, NATHAN REGINALD (DPT)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:REGINALD
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 819 BOX 18
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09645
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:HOSPITAL AMERICANO, BASE NAVAL DE ROTA
Practice Address - Street 2:APARTADO DE CORREOS 33
Practice Address - City:ROTA
Practice Address - State:CADIZ
Practice Address - Zip Code:11530
Practice Address - Country:ES
Practice Address - Phone:314-727-4029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL-00149132251P0200X
NV35722251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics