Healthcare Provider Details

I. General information

NPI: 1194411355
Provider Name (Legal Business Name): DANIEL PETERSON FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2023
Last Update Date: 11/28/2023
Certification Date: 11/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 E 3900 S STE 200
SALT LAKE CITY UT
84107-2332
US

IV. Provider business mailing address

470 E 3900 S STE 200
SALT LAKE CITY UT
84107-2332
US

V. Phone/Fax

Practice location:
  • Phone: 801-747-2800
  • Fax:
Mailing address:
  • Phone: 801-747-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10366644-8900
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: