Provider Demographics
NPI:1770321150
Name:PETERSEN, ISAIAH (DC)
Entity type:Individual
Prefix:DR
First Name:ISAIAH
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 NE DELAWARE AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50021-6691
Mailing Address - Country:US
Mailing Address - Phone:712-221-7690
Mailing Address - Fax:
Practice Address - Street 1:107 NE DELAWARE AVE STE 3
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50021-6691
Practice Address - Country:US
Practice Address - Phone:712-221-7690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA119384111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor