Healthcare Provider Details

I. General information

NPI: 1538673181
Provider Name (Legal Business Name): THOMAS PETERSON DNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2017
Last Update Date: 05/12/2021
Certification Date: 04/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16911 WILLOW GLEN RD.
BROWNSVILLE CA
95919
US

IV. Provider business mailing address

PO BOX 255228
SACRAMENTO CA
95865-5228
US

V. Phone/Fax

Practice location:
  • Phone: 530-675-0466
  • Fax:
Mailing address:
  • Phone: 916-708-8038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberNP35008779
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberF11170360
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number95008779
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: