Basic Information
| Provider Information | |||||||||
| NPI: | 1346363694 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | KARI | ||||||||
| MiddleName: | JOSEPHINE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DAVISSON | ||||||||
| OtherFirstName: | KARI | ||||||||
| OtherMiddleName: | JOSEPHINE | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2963 E COPPER POINT DR | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836429055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083228515 | ||||||||
| FaxNumber: | 2083221731 | ||||||||
| Practice Location | |||||||||
| Address1: | 2963 E COPPER POINT DR | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836429055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083221730 | ||||||||
| FaxNumber: | 2083221731 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2007 | ||||||||
| LastUpdateDate: | 09/08/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD183336 | OR | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | MD2009-0568 | NM | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | M-11248 | ID | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.