Provider Demographics
NPI:1063458636
Name:PETERS, CARL EDWIN (PA)
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:EDWIN
Last Name:PETERS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 INDIAN HILLS DR
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51104-1857
Mailing Address - Country:US
Mailing Address - Phone:712-258-4700
Mailing Address - Fax:712-258-4777
Practice Address - Street 1:1551 INDIAN HILLS DR
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51104-1859
Practice Address - Country:US
Practice Address - Phone:712-258-4700
Practice Address - Fax:712-258-4777
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001490363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant