Provider Demographics
NPI:1225497894
Name:PETERSEN, DAVID
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:PETERSEN
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 1:2319 PINE RUN RD
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:PA
Mailing Address - Zip Code:17744-8149
Mailing Address - Country:US
Mailing Address - Phone:929-724-2277
Mailing Address - Fax:
Practice Address - Street 1:3512 QUENTIN RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-4244
Practice Address - Country:US
Practice Address - Phone:888-515-3834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-11
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASPO15897363LF0000X
PASPO30250363LP0808X
NY2024030602363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily