MEDICARE: MR. EVAN J PETERSEN PT, OCS, ATC, CSCS

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	2251X0800X	Orthopedic Physical Therapist	3803	SC

General Provider Information

NPI Number	:	1609867548
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. EVAN J PETERSEN PT, OCS, ATC, CSCS

Provider Business Mailing Address
First Line	:	4601 RED ROCK PASS
Second Line	:
City	:	SCHERTZ
State	:	TX
Zip	:	78154-1123
Country	:	US
Telephone Number	:	210-455-3687
Fax Number	:

Provider Business Practice Location Address
First Line	:	3851 ROGER BROOKE DR
Second Line	:	BLDG 3600
City	:	FORT SAM HOUSTON
State	:	TX
Zip	:	78234-4501
Country	:	US
Telephone Number	:	210-916-1920
Fax Number	:	210-916-4074

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

Provider Enumeration Date	:	10/31/2005
Last Update Date	:	07/08/2007

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Directions to “ MR. EVAN J PETERSEN PT, OCS, ATC, CSCS” Practice Location

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