Provider Demographics
NPI:1033198957
Name:PETERSON, ROBERT (PA-C)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
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 1:707 ASH STREET
Mailing Address - Street 2:
Mailing Address - City:SPOONER
Mailing Address - State:WI
Mailing Address - Zip Code:54801
Mailing Address - Country:US
Mailing Address - Phone:715-635-2151
Mailing Address - Fax:
Practice Address - Street 1:707 ASH STREET
Practice Address - Street 2:
Practice Address - City:SPOONER
Practice Address - State:WI
Practice Address - Zip Code:54801
Practice Address - Country:US
Practice Address - Phone:715-635-2151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9873363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN209L9PEOtherBCBS
410849339 56001 G011OtherCHAMPUS
MNNA2951011331OtherPREFERRED ONE
MN110533700Medicaid
MN115317OtherUCARE
MN0117135OtherMEDICA
MNHP20659OtherHEALTH PARTNERS
MNNA2951011331OtherPREFERRED ONE
MNHP20659OtherHEALTH PARTNERS