Provider Demographics
NPI:1003217860
Name:PETERSON, KELLY MALIA (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MALIA
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1633
Mailing Address - Country:US
Mailing Address - Phone:734-647-5299
Mailing Address - Fax:
Practice Address - Street 1:1301 MERCY DRIVE
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444
Practice Address - Country:US
Practice Address - Phone:231-739-9492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-11
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007197363A00000X
MI363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant