Provider Demographics
NPI:1174613202
Name:PETERSON, DARRON (MPT, MED)
Entity type:Individual
Prefix:
First Name:DARRON
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MPT, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 879613
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99687-9613
Mailing Address - Country:US
Mailing Address - Phone:907-373-0280
Mailing Address - Fax:907-373-0280
Practice Address - Street 1:6341 S. CALISTA DR.
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654
Practice Address - Country:US
Practice Address - Phone:907-373-0280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1518225100000X
CA32803225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist