Provider Demographics
NPI:1003330036
Name:PETERSON, EVAN DOUGLAS (PA-C)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:DOUGLAS
Last Name:PETERSON
Suffix:
Gender:M
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 1:103 SW 3RD ST APT 403
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309-4832
Mailing Address - Country:US
Mailing Address - Phone:515-577-6220
Mailing Address - Fax:
Practice Address - Street 1:6520 SE 14TH ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50320-1846
Practice Address - Country:US
Practice Address - Phone:515-953-1500
Practice Address - Fax:515-953-2136
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-01
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA088343207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine