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General NPI Number Information
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NPI Number | 1316162647
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Entity Type | Individual
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Provider Name | KENT LEE PETERSON D.P.M.
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Gender | Male
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Dates
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Enumeration Date | 04/13/2007
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Last Update Date | 04/07/2017
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Provider Practice Location Address
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Address Line | 919 12TH PL SUITE 10
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City | PRESCOTT
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State | AZ
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Zip | 86305-1433
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Country | US
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Telephone | 928-776-0770
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Fax | 928-776-8991
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Provider Business Mailing Address
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Address Line | 1206 ROLLING HILLS CIR
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City | PRESCOTT
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State | AZ
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Zip | 86303-6485
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Country | US
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Telephone | 928-710-0770
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Fax | 928-445-3802
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | 0261
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License Number State | AZ
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