Healthcare Provider Details

I. General information

NPI: 1306809520
Provider Name (Legal Business Name): EVELYN PETERSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LYN PETERSON MD

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 11/27/2023
Certification Date: 06/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 SUNNYVIEW LN
KALISPELL MT
59901-3129
US

IV. Provider business mailing address

350 SUNNYVIEW LN
KALISPELL MT
59901-3129
US

V. Phone/Fax

Practice location:
  • Phone: 406-752-5111
  • Fax: 406-756-2703
Mailing address:
  • Phone: 406-752-5111
  • Fax: 406-756-2703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberM-8305
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number43861
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number2005007776
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: