Basic Information
| Provider Information | |||||||||
| NPI: | 1083887087 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSEN | ||||||||
| FirstName: | THEA | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 24410 | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419844301 | ||||||||
| FaxNumber: | 5413352527 | ||||||||
| Practice Location | |||||||||
| Address1: | 123 S 27TH ST | ||||||||
| Address2: | |||||||||
| City: | BILLINGS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 591014200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062473269 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2008 | ||||||||
| LastUpdateDate: | 10/08/2010 | ||||||||
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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 | 207Q00000X | MD152665 | OR | N | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.