Provider Demographics
NPI:1841966819
Name:PETERSON, RIO (PMHNP)
Entity type:Individual
Prefix:
First Name:RIO
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:260 BONNER MALL WAY # 1028
Mailing Address - Street 2:
Mailing Address - City:PONDERAY
Mailing Address - State:ID
Mailing Address - Zip Code:83852-9748
Mailing Address - Country:US
Mailing Address - Phone:209-677-7747
Mailing Address - Fax:888-849-5240
Practice Address - Street 1:4020 GRANITE VIEW ROAD
Practice Address - Street 2:
Practice Address - City:NEW MEADOWS
Practice Address - State:ID
Practice Address - Zip Code:83654
Practice Address - Country:US
Practice Address - Phone:209-677-7747
Practice Address - Fax:888-849-5240
Is Sole Proprietor?:No
Enumeration Date:2021-08-19
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ID70072363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health