Basic Information
| Provider Information | |||||||||
| NPI: | 1316326911 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | COREY | ||||||||
| MiddleName: | NATHANIEL | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8823 PRODUCTION LN | ||||||||
| Address2: | |||||||||
| City: | OOLTEWAH | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373636511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232387217 | ||||||||
| FaxNumber: | 4232383473 | ||||||||
| Practice Location | |||||||||
| Address1: | 1227 E 32ND ST | ||||||||
| Address2: | STE 7 | ||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648042880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4176247400 | ||||||||
| FaxNumber: | 4176247403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2015 | ||||||||
| LastUpdateDate: | 06/09/2015 | ||||||||
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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 | 225100000X | 2015017587 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 1259336 | TX | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.