Basic Information
| Provider Information | |||||||||
| NPI: | 1104933506 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | LINDA | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 PERIMETER PARK DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | MORRISVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275608442 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 701 DOCTORS DR STE E1 | ||||||||
| Address2: | |||||||||
| City: | KINSTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285011584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2527755930 | ||||||||
| FaxNumber: | 2522081177 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 08/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 45721 | WI | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 2020-02690 | NC | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 34392100 | 05 | WI | MEDICAID | BP8336528 | 01 | DEA NUMBER | OTHER |