Healthcare Provider Details

I. General information

NPI: 1184841231
Provider Name (Legal Business Name): TINA A PETERSEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 09/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 UNIVERSITY OF NEW MEXICO MSC10 5590
ALBUQUERQUE NM
87131-0001
US

IV. Provider business mailing address

PO BOX 36302
ALBUQUERQUE NM
87176-6302
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-3909
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberRS20070349
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD2010-0502
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: