Provider Demographics
NPI:1184480444
Name:PETERSON, XAVIER DEON (RN)
Entity type:Individual
Prefix:
First Name:XAVIER
Middle Name:DEON
Last Name:PETERSON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 REDWOOD ST
Mailing Address - Street 2:
Mailing Address - City:PORT GIBSON
Mailing Address - State:MS
Mailing Address - Zip Code:39150-2593
Mailing Address - Country:US
Mailing Address - Phone:716-322-9408
Mailing Address - Fax:
Practice Address - Street 1:260 NORTHERN AVE
Practice Address - Street 2:
Practice Address - City:AVONDALE ESTATES
Practice Address - State:GA
Practice Address - Zip Code:30002-1214
Practice Address - Country:US
Practice Address - Phone:716-322-9408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN323385163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse