Basic Information
| Provider Information | |||||||||
| NPI: | 1275106254 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | TED | ||||||||
| MiddleName: | STEVEN | ||||||||
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| Credential: | APN FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | BOX 78534 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532787150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153817322 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5875 EAST RIVERSIDE BLVD | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153989491 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2021 | ||||||||
| LastUpdateDate: | 12/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 209023474 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.