Provider Demographics
NPI:1245902402
Name:PETERSON, MAISON AVERY
Entity type:Individual
Prefix:
First Name:MAISON
Middle Name:AVERY
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10498 SW 156TH RD
Mailing Address - Street 2:
Mailing Address - City:WILBURTON
Mailing Address - State:OK
Mailing Address - Zip Code:74578-7607
Mailing Address - Country:US
Mailing Address - Phone:918-429-9862
Mailing Address - Fax:
Practice Address - Street 1:727 E WYANDOTTE AVE
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-5427
Practice Address - Country:US
Practice Address - Phone:918-420-5343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator