Provider Demographics
NPI:1275143562
Name:PETERSON, KEITH HJALMAR JUDE
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:HJALMAR JUDE
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 1:77 PARK AVE APT 127
Mailing Address - Street 2:
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-7106
Mailing Address - Country:US
Mailing Address - Phone:973-931-2812
Mailing Address - Fax:
Practice Address - Street 1:77 PARK AVE APT 127
Practice Address - Street 2:
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-7106
Practice Address - Country:US
Practice Address - Phone:973-931-2812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-03
Last Update Date:2020-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR17689800163W00000X
NJ26NJ01064600363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse