Provider Demographics
NPI:1609414168
Name:PETERSON HEALTHCARE LLC
Entity Type:Organization
Organization Name:PETERSON HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRADEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:APRN- CNP
Authorized Official - Phone:580-235-1657
Mailing Address - Street 1:540 S LAHOMA AVE
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-5526
Mailing Address - Country:US
Mailing Address - Phone:580-235-1657
Mailing Address - Fax:
Practice Address - Street 1:540 S LAHOMA AVE
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-5526
Practice Address - Country:US
Practice Address - Phone:580-235-1657
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-16
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty