Basic Information
| Provider Information | |||||||||
| NPI: | 1336645258 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSEN | ||||||||
| FirstName: | TEGAN | ||||||||
| MiddleName: | CLEO | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3307 BUTTERNUT DR | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805382617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704026349 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1613 PROSPECT PARK WAY STE 110 | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805259707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703779401 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2018 | ||||||||
| LastUpdateDate: | 03/30/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.