Basic Information
| Provider Information | |||||||||
| NPI: | 1659459139 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | GEOFFREY | ||||||||
| MiddleName: | DEANE | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1312 N GLEN DR | ||||||||
| Address2: | |||||||||
| City: | HIXSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373434344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236679367 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6925 SHALLOWFORD RD | ||||||||
| Address2: | APT 206 | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374211787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238940432 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 04/30/2008 | ||||||||
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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 | 363L00000X | 6940 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.