Basic Information
| Provider Information | |||||||||
| NPI: | 1780989590 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSEN | ||||||||
| FirstName: | HOANG | ||||||||
| MiddleName: | KIM | ||||||||
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| Credential: | NURSE PRACTITIONER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2550 N THUNDERBIRD CIR STE 303 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852151219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804554932 | ||||||||
| FaxNumber: | 4807760025 | ||||||||
| Practice Location | |||||||||
| Address1: | 16728 E SMOKY HILL RD UNIT 10D | ||||||||
| Address2: | |||||||||
| City: | CENTENNIAL | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800152400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037667006 | ||||||||
| FaxNumber: | 3037661023 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2011 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 1649 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LF0000X | NP-10342 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 283185101 | 05 | TX | MEDICAID | 283185102 | 05 | TX | MEDICAID | 78459834 | 05 | NM | MEDICAID | 283185104 | 05 | TX | MEDICAID | 200342180 A | 05 | OK | MEDICAID | 283185103 | 05 | TX | MEDICAID |