Provider Demographics
NPI:1770249542
Name:PETERSON, MATTHEW (NP)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9277 CANTERBURY LN
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-6405
Mailing Address - Country:US
Mailing Address - Phone:614-725-6232
Mailing Address - Fax:
Practice Address - Street 1:9277 CANTERBURY LN
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-6405
Practice Address - Country:US
Practice Address - Phone:614-725-6232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0030195363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily