Healthcare Provider Details

I. General information

NPI: 1285906321
Provider Name (Legal Business Name): MICHAEL PETERSON M.S., ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2012
Last Update Date: 07/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 N DIERS AVE SUITE 300
GRAND ISLAND NE
68803-4984
US

IV. Provider business mailing address

4021 ANNE MARIE AVE
GRAND ISLAND NE
68803-9702
US

V. Phone/Fax

Practice location:
  • Phone: 308-382-0344
  • Fax:
Mailing address:
  • Phone: 815-712-7636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096.002411
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: