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General NPI Number Information
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NPI Number | 1770593246
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Entity Type | Individual
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Provider Name | SHANE L PETERSEN MD
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Gender | Male
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Dates
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Enumeration Date | 08/08/2006
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Last Update Date | 12/29/2025
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Provider Practice Location Address
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Address Line | 5121 S COTTONWOOD STREET INTERMOUNTAIN MEDICAL CENTER
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City | MURRAY
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State | UT
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Zip | 84157
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Country | US
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Telephone | 801-507-5248
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Fax | 801-733-5618
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Provider Business Mailing Address
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Address Line | 3340 NORTH CENTER ST #800
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City | LEHI
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State | UT
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Zip | 84043-7406
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Country | US
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Telephone | 801-990-1911
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Fax | 801-990-1912
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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 | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | 2434068-1205
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License Number State | UT
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Taxonomy #2
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | MD227949
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License Number State | OR
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