Basic Information
| Provider Information | |||||||||
| NPI: | 1427080894 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | BRENT | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 550 | ||||||||
| Address2: | |||||||||
| City: | LOWELL | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727450550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794637775 | ||||||||
| FaxNumber: | 4794637864 | ||||||||
| Practice Location | |||||||||
| Address1: | 3336 N. FUTRALL DRIVE | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794633000 | ||||||||
| FaxNumber: | 4794633050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 01/10/2019 | ||||||||
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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 | 207T00000X | 2003013356 | MO | N | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | E-11020 | AR | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 100641320A | 05 | KS | MEDICAID | P00046311 | 01 | MO | RR MEDICARE | OTHER | 209001809 | 05 | MO | MEDICAID |