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NPI Code Detail

MEDICARE: MALIK PETERSON

MEDICARE: MALIK PETERSON
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
1390200000XStudent in an Organized Health Care Education/Training Program

General Provider Information

NPI Number : 1871396119
Entity Type Code : Individual
Provider Name (Legal Business Name) : MALIK PETERSON
Provider Business Mailing Address
First Line : 3100 CHANNING WAY
Second Line :
City : IDAHO FALLS
State : ID
Zip : 83404-7533
Country : US
Telephone Number : 208-970-1123
Fax Number :
Provider Business Practice Location Address
First Line : 3100 CHANNING WAY
Second Line :
City : IDAHO FALLS
State : ID
Zip : 83404-7533
Country : US
Telephone Number : 208-227-2850
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/31/2025
Last Update Date : 03/21/2026

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Directions to “ MALIK PETERSON ” Practice Location

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