Provider Demographics
NPI:1720332968
Name:PETERSON, SAMUEL NOLAN (AUD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:NOLAN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1867 WILLIAMS HWY
Mailing Address - Street 2:STE. 105
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-5854
Mailing Address - Country:US
Mailing Address - Phone:541-474-4694
Mailing Address - Fax:541-474-9590
Practice Address - Street 1:1867 WILLIAMS HWY
Practice Address - Street 2:STE. 105
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5854
Practice Address - Country:US
Practice Address - Phone:541-474-4694
Practice Address - Fax:541-474-9590
Is Sole Proprietor?:No
Enumeration Date:2012-11-08
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23642231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist