Provider Demographics
NPI:1083211395
Name:PETERSON, AARON OSCAR (PA STUDENT)
Entity Type:Individual
Prefix:
First Name:AARON
Middle Name:OSCAR
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PA STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 N PACIFIC ST APT 315
Mailing Address - Street 2:
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69101-3335
Mailing Address - Country:US
Mailing Address - Phone:507-676-0621
Mailing Address - Fax:
Practice Address - Street 1:215 MCNEEL LN
Practice Address - Street 2:
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101-6054
Practice Address - Country:US
Practice Address - Phone:308-568-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NE2491363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program