Provider Demographics
NPI:1033270905
Name:PETERS, KENT JON (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:KENT
Middle Name:JON
Last Name:PETERS
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
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Mailing Address - Street 1:4101 WOOLWORTH AVE
Mailing Address - Street 2:VA OMAHA HOSPITAL
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68105
Mailing Address - Country:US
Mailing Address - Phone:402-995-4463
Mailing Address - Fax:402-995-5163
Practice Address - Street 1:4101 WOOLWORTH AVE
Practice Address - Street 2:VA OMAHA HOSPITAL
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68105
Practice Address - Country:US
Practice Address - Phone:402-995-4463
Practice Address - Fax:402-995-5163
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE703363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S59491Medicare UPIN
NE279417Medicare ID - Type Unspecified