Provider Demographics
NPI:1780126680
Name:PETERSON, MEKENNA (ATC, SA)
Entity type:Individual
Prefix:
First Name:MEKENNA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:ATC, SA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15209 W 48TH AVE
Mailing Address - Street 2:
Mailing Address - City:GOLDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80403-1722
Mailing Address - Country:US
Mailing Address - Phone:563-580-3756
Mailing Address - Fax:
Practice Address - Street 1:2150 STADIUM DRIVE FLOOR 2
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80309-9117
Practice Address - Country:US
Practice Address - Phone:303-315-9900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-08
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO20-0208246ZX2200X
390200000X
COAT.00019782255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty
No246ZX2200XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherOrthopedic AssistantGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program