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Individual
DR. NICKALOS LEE PETERSON
Active
Individual
DR. NICKALOS LEE PETERSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
D.C.
Taxonomy
Speciality
Code
Description
License number
State
111N00000X
Chiropractor
Primary
180
CT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0114667
AETNA HMO ID NUMBER
CT
01
—
050000180CT01
ANTHEM BC/BS ID PROVIDER
CT
01
—
4380815
AETNA PPO ID NUMBER
CT
01
—
9323280003
CIGNA PROVIDER ID NUMBER
CT
01
—
LANDMARK /HEALTH NET
CT00180 PROVIDER ID#
CT
01
—
P405105
OXFORD PROVIDER ID NUMBER
CT
Enumeration date
09/21/2006
Last updated
07/08/2007
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