Provider Demographics
NPI:1144703653
Name:PETERS, QUINTON JARRETT (ATC, LAT, EMT-B)
Entity type:Individual
Prefix:
First Name:QUINTON
Middle Name:JARRETT
Last Name:PETERS
Suffix:
Gender:M
Credentials:ATC, LAT, EMT-B
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:KAUKAUNA
Mailing Address - State:WI
Mailing Address - Zip Code:54130-1230
Mailing Address - Country:US
Mailing Address - Phone:715-498-1996
Mailing Address - Fax:
Practice Address - Street 1:1510 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:KAUKAUNA
Practice Address - State:WI
Practice Address - Zip Code:54130-1230
Practice Address - Country:US
Practice Address - Phone:715-498-1996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI70107210207PE0004X
WI2261-392255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer