Healthcare Provider Details

I. General information

NPI: 1023401882
Provider Name (Legal Business Name): BRIAN PETERSON REGISTERED NURSE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2015
Last Update Date: 04/09/2023
Certification Date: 04/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 N JOHNSON AVE STE 101
EL CAJON CA
92020-1651
US

IV. Provider business mailing address

1400 N JOHNSON AVE STE 101
EL CAJON CA
92020-1651
US

V. Phone/Fax

Practice location:
  • Phone: 619-442-0277
  • Fax:
Mailing address:
  • Phone: 619-442-0277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number748137
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number748137
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: