Provider Demographics
NPI:1134439755
Name:PETERSEN, JAMES TYLER (DC)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:TYLER
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:657 W 200 N
Mailing Address - Street 2:
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84720-2408
Mailing Address - Country:US
Mailing Address - Phone:435-592-4845
Mailing Address - Fax:
Practice Address - Street 1:657 W 200 N
Practice Address - Street 2:
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84720-2408
Practice Address - Country:US
Practice Address - Phone:435-592-4845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-15
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1429111N00000X
UT7779072-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000073714OtherPTAN