Basic Information
| Provider Information | |||||||||
| NPI: | 1194744896 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26 QUEEN STREET | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016102473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088607800 | ||||||||
| FaxNumber: | 5088607973 | ||||||||
| Practice Location | |||||||||
| Address1: | 26 QUEEN ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088607800 | ||||||||
| FaxNumber: | 5088607973 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 07/18/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN192039 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0322938 | 05 | MA | MEDICAID |