Provider Demographics
NPI:1356610810
Name:PETERSON, MATTHEW ADAM (RN)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:ADAM
Last Name:PETERSON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 125TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:FINLEY
Mailing Address - State:ND
Mailing Address - Zip Code:58230-9422
Mailing Address - Country:US
Mailing Address - Phone:207-360-9218
Mailing Address - Fax:
Practice Address - Street 1:198 125TH AVE NE
Practice Address - Street 2:
Practice Address - City:FINLEY
Practice Address - State:ND
Practice Address - Zip Code:58230-9422
Practice Address - Country:US
Practice Address - Phone:207-360-9218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-29
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201143593RN163WP0808X
WARN60364923163WP0808X
NDR33126163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health