Provider Demographics
NPI:1558307884
Name:PETERSON, LORI (MD)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1892 WILLIAMS STREET
Mailing Address - Street 2:
Mailing Address - City:FT. HARRISON
Mailing Address - State:MT
Mailing Address - Zip Code:59636
Mailing Address - Country:US
Mailing Address - Phone:406-447-7553
Mailing Address - Fax:406-447-7991
Practice Address - Street 1:1892 WILLIAMS STREET
Practice Address - Street 2:
Practice Address - City:FT. HARRISON
Practice Address - State:MT
Practice Address - Zip Code:59636
Practice Address - Country:US
Practice Address - Phone:406-447-7553
Practice Address - Fax:406-447-7991
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO26412207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology