MEDICARE: CONNIE LEE PETERSON ATC, PHD

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	2255A2300X	Athletic Trainer	0126000622	VA

General Provider Information

NPI Number	:	1811953342
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CONNIE LEE PETERSON ATC, PHD

Provider Business Mailing Address
First Line	:	3839 MILL RACE CT
Second Line	:
City	:	HARRISONBURG
State	:	VA
Zip	:	22801-2270
Country	:	US
Telephone Number	:	540-568-7085
Fax Number	:	540-568-3336

Provider Business Practice Location Address
First Line	:	JAMES MADISON UNIVERSITY
Second Line	:	MSC 4301
City	:	HARRISONBURG
State	:	VA
Zip	:	22807-0001
Country	:	US
Telephone Number	:	540-568-7085
Fax Number	:	540-568-3336

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

Provider Enumeration Date	:	04/24/2006
Last Update Date	:	07/08/2007

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