MEDICARE: DR. TAMARA LEE PETERSON D.O.

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	208000000X	Pediatrics Physician	2005018438	MO

General Provider Information

NPI Number	:	1902063506
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TAMARA LEE PETERSON D.O.

Provider Business Mailing Address
First Line	:	3171 NE CARNEGIE DR
Second Line	:	SUITE A
City	:	LEES SUMMIT
State	:	MO
Zip	:	64064-3215
Country	:	US
Telephone Number	:	816-525-2800
Fax Number	:	816-525-4077

Provider Business Practice Location Address
First Line	:	3171 NE CARNEGIE DR
Second Line	:	SUITE A
City	:	LEES SUMMIT
State	:	MO
Zip	:	64064-3215
Country	:	US
Telephone Number	:	816-525-2800
Fax Number	:	816-525-4077

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/21/2008
Last Update Date	:	04/26/2016

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