Healthcare Provider Details

I. General information

NPI: 1891569653
Provider Name (Legal Business Name): R PETERSON PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2023
Last Update Date: 12/18/2023
Certification Date: 12/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1490 E FOREMASTER DR STE 260
ST GEORGE UT
84790-4502
US

IV. Provider business mailing address

1490 E FOREMASTER DR STE 260
ST GEORGE UT
84790-4502
US

V. Phone/Fax

Practice location:
  • Phone: 435-523-3378
  • Fax: 435-523-3376
Mailing address:
  • Phone: 435-523-3378
  • Fax: 435-523-3376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. RYAN T PETERSON
Title or Position: AUTHORIZED OFFICIAL
Credential: DPM
Phone: 435-523-3370