Provider Demographics
NPI:1578751749
Name:PETERSON, TRAVIS J (FNP)
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:J
Last Name:PETERSON
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 COLLEGE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-8525
Mailing Address - Country:US
Mailing Address - Phone:904-213-2700
Mailing Address - Fax:
Practice Address - Street 1:400 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-8523
Practice Address - Country:US
Practice Address - Phone:904-213-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-12
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11023526363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily