Healthcare Provider Details

I. General information

NPI: 1831188473
Provider Name (Legal Business Name): LAURA JEAN PETERSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 11/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 E BOGARD RD STE 233
WASILLA AK
99654-7184
US

IV. Provider business mailing address

950 E BOGARD RD STE 233
WASILLA AK
99654-7184
US

V. Phone/Fax

Practice location:
  • Phone: 907-357-4543
  • Fax: 907-357-4533
Mailing address:
  • Phone: 907-357-4543
  • Fax: 907-357-4533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number6445
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: