Provider Demographics
NPI:1356605117
Name:PETERSON, LAURA MARIE (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8330 CHENEY RIDGE RD APT 439
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-3820
Mailing Address - Country:US
Mailing Address - Phone:402-730-6854
Mailing Address - Fax:
Practice Address - Street 1:8330 CHENEY RIDGE RD APT 439
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-3820
Practice Address - Country:US
Practice Address - Phone:402-730-6854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-26
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE30423208D00000X
MO390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice