Provider Demographics
NPI:1902277908
Name:PETERSON, TIA (NP-C)
Entity Type:Individual
Prefix:
First Name:TIA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 N GATEWAY DR STE 801
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-9004
Mailing Address - Country:US
Mailing Address - Phone:435-787-1023
Mailing Address - Fax:435-787-1882
Practice Address - Street 1:435 N GATEWAY DR STE 801
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-9004
Practice Address - Country:US
Practice Address - Phone:435-787-1023
Practice Address - Fax:435-787-1882
Is Sole Proprietor?:No
Enumeration Date:2015-10-15
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT324961-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily