Basic Information
| Provider Information | |||||||||
| NPI: | 1386900728 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSEN | ||||||||
| FirstName: | SAM | ||||||||
| MiddleName: | RICHARD | ||||||||
| NamePrefix: | |||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 SIVLEY RD SW STE 500 | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358015177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2562653881 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 201 SIVLEY RD SW STE 500 | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358015177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2562653881 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2012 | ||||||||
| LastUpdateDate: | 04/10/2012 | ||||||||
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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 | 163W00000X | 1-109909 | AL | Y | Nursing Service Providers | Registered Nurse |
No ID Information.