Provider Demographics
NPI:1679378616
Name:PETERSEN, JOHN (NREMT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:
Credentials:NREMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 FAIRFAX BLVD APT 2521
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-2450
Mailing Address - Country:US
Mailing Address - Phone:912-662-9901
Mailing Address - Fax:
Practice Address - Street 1:6550 RILEY RD
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20187-2508
Practice Address - Country:US
Practice Address - Phone:540-349-9004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-14
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX768753146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program