Healthcare Provider Details

I. General information

NPI: 1609414168
Provider Name (Legal Business Name): PETERSON HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2019
Last Update Date: 03/06/2026
Certification Date: 03/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 N HARRISON AVE STE 109
BLANCHARD OK
73010-6217
US

IV. Provider business mailing address

217 N HARRISON AVE STE 109
BLANCHARD OK
73010-6217
US

V. Phone/Fax

Practice location:
  • Phone: 405-888-8483
  • Fax: 918-803-4861
Mailing address:
  • Phone: 405-888-8483
  • Fax: 918-803-4861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRADEN PETERSON
Title or Position: NURSE PRACTITIONER / OWNER
Credential: APRN-CNP
Phone: 405-677-3378