Provider Demographics
NPI:1356410799
Name:PETERSON, RONALD LEON (PT)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:LEON
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 VALLEY VIEW CIR
Mailing Address - Street 2:
Mailing Address - City:PHOENIXVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19460-3185
Mailing Address - Country:US
Mailing Address - Phone:610-935-8333
Mailing Address - Fax:610-994-1670
Practice Address - Street 1:116 VALLEY VIEW CIR
Practice Address - Street 2:
Practice Address - City:PHOENIXVILLE
Practice Address - State:PA
Practice Address - Zip Code:19460-3185
Practice Address - Country:US
Practice Address - Phone:610-935-8333
Practice Address - Fax:610-994-1670
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT-0003733L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA045663Medicare ID - Type UnspecifiedPROVIDER NUMBER