MEDICARE: TONJA S PETERSEN - ANDERSON ARNP

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	363L00000X	Nurse Practitioner	A097418	IA

General Provider Information

NPI Number	:	1487626719
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TONJA S PETERSEN - ANDERSON ARNP

Provider Business Mailing Address
First Line	:	1351 W MAIN ST
Second Line	:	PO BOX 114
City	:	LAKE CITY
State	:	IA
Zip	:	51449-1585
Country	:	US
Telephone Number	:	712-464-7907
Fax Number	:	712-464-7412

Provider Business Practice Location Address
First Line	:	1351 W MAIN ST
Second Line	:
City	:	LAKE CITY
State	:	IA
Zip	:	51449-1585
Country	:	US
Telephone Number	:	712-464-7907
Fax Number	:	712-464-7412

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

Provider Enumeration Date	:	02/02/2006
Last Update Date	:	09/10/2015

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