Individual
BRENT P PETERSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
3336 N. FUTRALL DRIVE, FAYETTEVILLE, AR 72703
(479) 463-3000
(479) 463-3050
Mailing address
PO BOX 550, LOWELL, AR 72745-0550
(479) 463-7775
(479) 463-7864
Taxonomy
Speciality
Code
Description
License number
State
207T00000X
Neurological Surgery Physician
2003013356
MO
207T00000X
Neurological Surgery Physician
Primary
E-11020
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100641320A
—
KS
05
—
209001809
—
MO
01
—
P00046311
RR MEDICARE
MO
Enumeration date
07/07/2006
Last updated
01/10/2019
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