Provider Demographics
NPI:1659459139
Name:PETERSON, GEOFFREY DEANE (APN)
Entity Type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:DEANE
Last Name:PETERSON
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1312 N GLEN DR
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-4344
Mailing Address - Country:US
Mailing Address - Phone:423-667-9367
Mailing Address - Fax:
Practice Address - Street 1:6925 SHALLOWFORD RD
Practice Address - Street 2:APT 206
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-1787
Practice Address - Country:US
Practice Address - Phone:423-894-0432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6940363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNOTH000Medicare UPIN
3726561Medicare PIN
3370172Medicare PIN