Provider Demographics
NPI:1780989590
Name:PETERSEN, HOANG KIM (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:HOANG
Middle Name:KIM
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 N THUNDERBIRD CIR STE 303
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85215-1219
Mailing Address - Country:US
Mailing Address - Phone:480-455-4932
Mailing Address - Fax:480-776-0025
Practice Address - Street 1:16728 E SMOKY HILL RD UNIT 10D
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80015-2400
Practice Address - Country:US
Practice Address - Phone:303-766-7006
Practice Address - Fax:303-766-1023
Is Sole Proprietor?:No
Enumeration Date:2011-01-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1649363LP0200X
CONP-10342363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX283185101Medicaid
TX283185102Medicaid
NM78459834Medicaid
TX283185104Medicaid
OK200342180 AMedicaid
TX283185103Medicaid
TXTXB132644Medicare PIN
NM78459834Medicaid