Provider Demographics
NPI:1396528717
Name:PETERS, CLINT
Entity type:Individual
Prefix:
First Name:CLINT
Middle Name:
Last Name:PETERS
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 1:2623 WALNUT ST APT 91
Mailing Address - Street 2:
Mailing Address - City:CEDAR FALLS
Mailing Address - State:IA
Mailing Address - Zip Code:50613-5075
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2301 HUDSON RD SUITE NUMBER 003G HPC
Practice Address - Street 2:
Practice Address - City:CEDAR FALLS
Practice Address - State:IA
Practice Address - Zip Code:50614-0001
Practice Address - Country:US
Practice Address - Phone:319-273-7401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program