Provider Demographics
NPI:1538188479
Name:PETERSON, NORDELL E (PT)
Entity type:Individual
Prefix:
First Name:NORDELL
Middle Name:E
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 SOUTH 1500 EAST
Mailing Address - Street 2:
Mailing Address - City:CLEARFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84015-1633
Mailing Address - Country:US
Mailing Address - Phone:801-397-4340
Mailing Address - Fax:801-397-4390
Practice Address - Street 1:1425 S 1500 E
Practice Address - Street 2:
Practice Address - City:CLEARFIELD
Practice Address - State:UT
Practice Address - Zip Code:84015-1621
Practice Address - Country:US
Practice Address - Phone:801-779-0798
Practice Address - Fax:801-779-2798
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1101962401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT460488423001Medicaid
UT460488423001Medicaid