Provider Demographics
NPI:1821639444
Name:PETERSON, CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6585 HAINES RD N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-6137
Mailing Address - Country:US
Mailing Address - Phone:440-315-8503
Mailing Address - Fax:727-954-6408
Practice Address - Street 1:6585 HAINES RD N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-6137
Practice Address - Country:US
Practice Address - Phone:440-315-8503
Practice Address - Fax:727-954-6408
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-04
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor