Provider Demographics
NPI:1558112326
Name:PETERSON, ETHAN E (DC)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:E
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1521 E 50TH ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64110-2343
Mailing Address - Country:US
Mailing Address - Phone:785-979-0690
Mailing Address - Fax:
Practice Address - Street 1:4049 PENNSYLVANIA AVE STE 100
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-3022
Practice Address - Country:US
Practice Address - Phone:816-301-4355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-29
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024003248111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor