Provider Demographics
NPI:1821012386
Name:PETERSON, JAY WADEMAN (CNP)
Entity Type:Individual
Prefix:MR
First Name:JAY
Middle Name:WADEMAN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 CEDAR ST SE
Mailing Address - Street 2:STE 800
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4917
Mailing Address - Country:US
Mailing Address - Phone:505-563-2800
Mailing Address - Fax:505-563-2821
Practice Address - Street 1:201 CEDAR ST SE
Practice Address - Street 2:STE 800
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4917
Practice Address - Country:US
Practice Address - Phone:505-563-2800
Practice Address - Fax:505-563-2821
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR48991363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM47737352Medicaid
NMQ13603Medicare UPIN
NM47737352Medicaid