Healthcare Provider Details

I. General information

NPI: 1700181922
Provider Name (Legal Business Name): KARL ROBERT PETERSON APRN CNM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2011
Last Update Date: 01/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 GOLDEN CHERRY DR
GROVER MO
63040-1658
US

IV. Provider business mailing address

317 GOLDEN CHERRY DR
GROVER MO
63040-1658
US

V. Phone/Fax

Practice location:
  • Phone: 636-273-1298
  • Fax:
Mailing address:
  • Phone: 636-273-1298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number2003021203
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: