Healthcare Provider Details

I. General information

NPI: 1891780862
Provider Name (Legal Business Name): PAUL CARL PETERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 06/24/2020
Certification Date: 06/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 20TH ST SUITE 503
KNOXVILLE TN
37916-1809
US

IV. Provider business mailing address

501 20TH ST SUITE 503
KNOXVILLE TN
37916
US

V. Phone/Fax

Practice location:
  • Phone: 865-541-4321
  • Fax: 865-541-4320
Mailing address:
  • Phone: 865-541-4321
  • Fax: 865-541-4320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberMD0000027743
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: