Provider Demographics
NPI:1891569653
Name:R PETERSON PC
Entity Type:Organization
Organization Name:R PETERSON PC
Other - Org Name:RYAN PETERSON DPM
Other - Org Type:Other Name
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:435-523-3370
Mailing Address - Street 1:1490 E FOREMASTER DR STE 260
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-4502
Mailing Address - Country:US
Mailing Address - Phone:435-523-3378
Mailing Address - Fax:435-523-3376
Practice Address - Street 1:1490 E FOREMASTER DR STE 260
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-4502
Practice Address - Country:US
Practice Address - Phone:435-523-3378
Practice Address - Fax:435-523-3376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-13
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty