Provider Demographics
NPI:1144337338
Name:PETERSON, ANDREW ERIC (DC)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:ERIC
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1251 SHELL BEACH RD
Mailing Address - Street 2:PO BOX 3407
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449
Mailing Address - Country:US
Mailing Address - Phone:805-773-1251
Mailing Address - Fax:804-773-3961
Practice Address - Street 1:1251 SHELL BEACH RD
Practice Address - Street 2:
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449
Practice Address - Country:US
Practice Address - Phone:805-773-1251
Practice Address - Fax:804-773-3961
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 16477111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC16477Medicare PIN
T06152Medicare UPIN