Healthcare Provider Details

I. General information

NPI: 1427080894
Provider Name (Legal Business Name): BRENT P PETERSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 01/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3336 N. FUTRALL DRIVE
FAYETTEVILLE AR
72703
US

IV. Provider business mailing address

PO BOX 550
LOWELL AR
72745-0550
US

V. Phone/Fax

Practice location:
  • Phone: 479-463-3000
  • Fax: 479-463-3050
Mailing address:
  • Phone: 479-463-7775
  • Fax: 479-463-7864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number2003013356
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberE-11020
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: