Healthcare Provider Details

I. General information

NPI: 1194135350
Provider Name (Legal Business Name): NATHAN ROBERT PETERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2014
Last Update Date: 03/29/2024
Certification Date: 03/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 N 500 W
PROVO UT
84604-3380
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-357-7575
  • Fax:
Mailing address:
  • Phone: 801-357-7575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number12407595-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: