Provider Demographics
NPI:1215105804
Name:PETERSEN, JASON DAYNE (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:DAYNE
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5353 S 960 E
Mailing Address - Street 2:#150
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-3569
Mailing Address - Country:US
Mailing Address - Phone:801-971-8684
Mailing Address - Fax:
Practice Address - Street 1:5353 S 960 E
Practice Address - Street 2:#150
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-3569
Practice Address - Country:US
Practice Address - Phone:801-261-5791
Practice Address - Fax:801-747-7740
Is Sole Proprietor?:No
Enumeration Date:2008-02-15
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT83185641205208200000X, 2082S0099X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery