Basic Information
| Provider Information | |||||||||
| NPI: | 1790112050 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MSN FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | W2421 SNOWBERRY DR | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549157484 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9202050413 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4100 DEWEY ST | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542205497 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9206865700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2013 | ||||||||
| LastUpdateDate: | 11/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 5433-33 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 5433-33 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 100034550 | 05 | WI | MEDICAID |