Healthcare Provider Details

I. General information

NPI: 1053459867
Provider Name (Legal Business Name): NATHAN RANDALL PETERSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 02/09/2026
Certification Date: 02/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SANTA MARGARITA
CAMP PENLETON CA
92055
US

IV. Provider business mailing address

573 TARKILN OAK CIR
PENSACOLA FL
32506-9677
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-1288
  • Fax:
Mailing address:
  • Phone: 850-492-6381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number39020000X
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: