Provider Demographics
NPI:1548317175
Name:PETERMAN, ROBERT CLAYTON (DOM, LMT, LAC)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:CLAYTON
Last Name:PETERMAN
Suffix:
Gender:M
Credentials:DOM, LMT, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2172
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-2172
Mailing Address - Country:US
Mailing Address - Phone:307-587-5951
Mailing Address - Fax:
Practice Address - Street 1:1907 BECK AVE
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-3928
Practice Address - Country:US
Practice Address - Phone:307-587-5951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDOM 775171100000X
PAAK000703171100000X
NM4307225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered171100000XOther Service ProvidersAcupuncturist
Not Answered225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY314457OtherBLUE CROSS OF WYOMING