MEDICARE: PETERSON WELLNESS PRIMARY CARE AND PEDIATRICS, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1851062517
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PETERSON WELLNESS PRIMARY CARE AND PEDIATRICS, PLLC

Provider Business Mailing Address
First Line	:	9701 SPRING LAKE DR
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74014-3426
Country	:	US
Telephone Number	:	918-724-3952
Fax Number	:

Provider Business Practice Location Address
First Line	:	109 W COMMERCIAL ST
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012-4012
Country	:	US
Telephone Number	:	918-724-3952
Fax Number	:

Authorized Official
Title or Position	:	NURSE PRACTITIONER, OWNER
Name	:	ASHTON DANIELLE PETERSON
Credential	:	NP
Telephone Number	:	918-724-3952

Provider Enumeration Date	:	09/22/2021
Last Update Date	:	09/22/2021

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