Individual
MAVERICK LEE PETERSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
224 W D. L. INGRAM AVENUE, BLDG. 1408, CANNON AFB, NM 88103
(715) 817-6949
Mailing address
224 W D. L. INGRAM AVENUE, BLDG. 1408, CANNON AFB, NM 88103
Taxonomy
Speciality
Code
Description
License number
State
1710I1003X
Independent Duty Medical Technicians
Primary
—
—
Other
Enumeration date
09/21/2023
Last updated
02/02/2024
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