Provider Demographics
NPI:1831188473
Name:PETERSON, LAURA JEAN (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:JEAN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 E BOGARD RD
Mailing Address - Street 2:STE 233
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7184
Mailing Address - Country:US
Mailing Address - Phone:907-357-4543
Mailing Address - Fax:907-357-4533
Practice Address - Street 1:950 E BOGARD RD
Practice Address - Street 2:STE 233
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7184
Practice Address - Country:US
Practice Address - Phone:907-357-4543
Practice Address - Fax:907-357-4533
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK6445208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics