Provider Demographics
NPI:1194248674
Name:PETERSON, TERRENCE WAYNE
Entity type:Individual
Prefix:MR
First Name:TERRENCE
Middle Name:WAYNE
Last Name:PETERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 GRAY ST
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:CO
Mailing Address - Zip Code:80214-1141
Mailing Address - Country:US
Mailing Address - Phone:303-884-0565
Mailing Address - Fax:
Practice Address - Street 1:2424 GRAY ST
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:CO
Practice Address - Zip Code:80214-1141
Practice Address - Country:US
Practice Address - Phone:303-884-0565
Practice Address - Fax:303-884-0565
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-17
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications