Provider Demographics
NPI:1760878011
Name:PETERSON, CARL (MBA, ATP)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MBA, ATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 218418
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77218-8418
Mailing Address - Country:US
Mailing Address - Phone:281-492-2799
Mailing Address - Fax:281-492-7479
Practice Address - Street 1:16820 BARKER SPRINGS RD
Practice Address - Street 2:SUITE E500
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77084-5040
Practice Address - Country:US
Practice Address - Phone:281-492-2799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-14
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXATP85795247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXATP85795OtherRESNA