Maverick Lee Peterson

Primary specialty

Independent Duty Medical TechniciansTaxonomy code 1710I1003X

Practice address

224 W D. L. Ingram Avenue, BLDG. 1408
Cannon Afb, NM 88103

Phone

(715) 817-6949

NPI assigned

Sep 21, 2023

Sex

Male

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

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

{
    "created_epoch": "1695254400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1706832000000",
    "number": "1346028149",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "224 W D. L. INGRAM AVENUE, BLDG. 1408",
            "city": "CANNON AFB",
            "state": "NM",
            "postal_code": "88103"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "224 W D. L. INGRAM AVENUE, BLDG. 1408",
            "city": "CANNON AFB",
            "state": "NM",
            "postal_code": "88103",
            "telephone_number": "715-817-6949"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETERSON",
        "first_name": "MAVERICK",
        "middle_name": "LEE",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2023-09-21",
        "last_updated": "2024-02-02",
        "certification_date": "2024-01-31",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1710I1003X",
            "taxonomy_group": "",
            "desc": "Military Health Care Provider, Independent Duty Medical Technicians",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Tyler Kinson Palbicke, MD
• Randi Parker, LCSW
• Anar J Patel, MD
• Sarah Alicia Paulson, PT, DPT
• John Michael Peffer, MD
• Priscilla Phan, PSYD
• Jodi Lynn Post, P.A.
• Jessica Marie Pothast, PHARMD
• Jordan Ramil, LCSW
• Michael Alonso Ramirez, MD

• Independent Duty Medical Technicians in Cannon Afb, NM
• Providers in Cannon Afb, NM by specialty
• Independent Duty Medical Technicians in New Mexico

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 2, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.