Provider Demographics
NPI:1609439066
Name:PETERSON, SHANE STEAN (DO)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:STEAN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7978 W MARY JANE LN
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-4864
Mailing Address - Country:US
Mailing Address - Phone:615-545-5080
Mailing Address - Fax:
Practice Address - Street 1:80 SEYMOUR ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-3315
Practice Address - Country:US
Practice Address - Phone:860-972-2864
Practice Address - Fax:860-545-5646
Is Sole Proprietor?:No
Enumeration Date:2019-04-20
Last Update Date:2020-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program