MEDICARE: TESS PETERSEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program	490438	PA

General Provider Information

NPI Number	:	1235691486
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TESS PETERSEN

Provider Business Mailing Address
First Line	:	100 E LANCASTER AVE
Second Line	:
City	:	WYNNEWOOD
State	:	PA
Zip	:	19096-3450
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 E LANCASTER AVE
Second Line	:
City	:	WYNNEWOOD
State	:	PA
Zip	:	19096-3450
Country	:	US
Telephone Number	:	484-476-6424
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/04/2019
Last Update Date	:	03/09/2026

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Directions to “ TESS PETERSEN ” Practice Location

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