Provider Demographics
NPI:1669432076
Name:PETERSON, JAMES CHRISTIAN (MSPT)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:CHRISTIAN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:J
Other - Middle Name:CHRISTIAN
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:50 E JAMES COURT
Mailing Address - Street 2:SUITE A
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-895-0715
Mailing Address - Fax:208-895-0746
Practice Address - Street 1:50 E JAMES COURT
Practice Address - Street 2:SUITE A
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-895-0715
Practice Address - Fax:208-895-0746
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT1526225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
136528Medicare ID - Type Unspecified