Provider Demographics
NPI:1790112050
Name:PETERSON, ERIC L (MSN FNP-BC)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:L
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MSN FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W2421 SNOWBERRY DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-7484
Mailing Address - Country:US
Mailing Address - Phone:920-205-0413
Mailing Address - Fax:
Practice Address - Street 1:4100 DEWEY ST
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-5497
Practice Address - Country:US
Practice Address - Phone:920-686-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-02
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5433-33363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100034550Medicaid