Provider Demographics
NPI:1780678193
Name:PETERSON, DONALD (PT)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1257 KS 99 HWY
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:KS
Mailing Address - Zip Code:67045
Mailing Address - Country:US
Mailing Address - Phone:620-583-7717
Mailing Address - Fax:
Practice Address - Street 1:1503 WASHINGTON LN
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:KS
Practice Address - Zip Code:67010-1638
Practice Address - Country:US
Practice Address - Phone:316-775-0700
Practice Address - Fax:316-775-0730
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1102114225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS140880OtherBLUE CROSS BLUE SHIELD
KS14295OtherPERFERRED PLUS OF KANSAS
KS14295OtherPERFERRED PLUS OF KANSAS