Basic Information
| Provider Information | |||||||||
| NPI: | 1538673181 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 255228 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958655228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167088038 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 16911 WILLOW GLEN RD. | ||||||||
| Address2: | |||||||||
| City: | BROWNSVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306750466 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2017 | ||||||||
| LastUpdateDate: | 05/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | NP35008779 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | F11170360 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 95008779 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.