Provider Demographics
NPI:1194411355
Name:PETERSON, DANIEL (FNP-C)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 E 3900 S STE 200
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-2332
Mailing Address - Country:US
Mailing Address - Phone:801-747-2800
Mailing Address - Fax:
Practice Address - Street 1:470 E 3900 S STE 200
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-2332
Practice Address - Country:US
Practice Address - Phone:801-747-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-12
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10366644-8900363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT260022408OtherRAILROAD MEDICARE
UT8760003008007Medicaid
UT000055266OtherMEDICARE PIN