Andrew D Petersen, DO

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

8382699-1204 Issued in UT

Practice address

524 W 300 N Ste 203
Provo, UT 84601-2669

Phone

(801) 607-5268

Fax

(801) 607-5271

NPI assigned

Aug 31, 2005

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Opted out of Medicare

Yes, effective Jun 13, 2016 through Jun 13, 2028

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Osteopathy, Doctor of Medicine

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Whole Health Medical Group

  • Specialist
  • Provo, UT
  • NPI 1285011452
  NPD (past) Authorized official
• Wholehealth Medical and Wellness

  • Family Medicine Physician
  • Provo, UT
  • NPI 1356728877

  Family Medicine

  NPD (past)
• Deer Land Emergency Physicians PLLC

  • Emergency Medicine Physician
  • Pampa, TX
  • NPI 1447543707
  NPD (past)
• Preferred Hospital Leasing Inc

  • Rural Health Clinic/Center
  • Wellington, TX
  • NPI 1407893316

  Family Medicine

  NPD (past)
• Preferred Hospital Leasing Inc.

  • Critical Access Hospital
  • Wellington, TX
  • NPI 1477594299
  NPD (past)
• Ranch Road Inpatient Services

  • Hospitalist Physician
  • Pampa, TX
  • NPI 1922367689
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1125446400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1400630400000",
    "number": "1124011572",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "524 W 300 N STE 203",
            "city": "PROVO",
            "state": "UT",
            "postal_code": "846012669",
            "telephone_number": "801-607-5268",
            "fax_number": "801-607-5271"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "524 W 300 N STE 203",
            "city": "PROVO",
            "state": "UT",
            "postal_code": "846012669",
            "telephone_number": "801-607-5268",
            "fax_number": "801-607-5271"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETERSEN",
        "first_name": "ANDREW",
        "middle_name": "D",
        "credential": "DO",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-08-31",
        "last_updated": "2014-05-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "TX",
            "license": "M4441",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "UT",
            "license": "8382699-1204",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "184033201",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "TAXONOMY",
            "identifier": "207Q00000X",
            "state": "KS"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Megan Perry
• Michael Perry
• Tanner Gardner Perry, DMD
• Stephen Peters, PSYD
• Dantzel Lily Petersen-Hancey
• Danielle Karin Petersen
• Nicholas Dee Petersen, DDS
• Riley Wayne Petersen, PMHNP
• Rodney C Petersen, MD
• Tiffani Petersen, NP

• All providers in Provo, UT
• Family Medicine Physician in Utah

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 21, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.