Provider Demographics
NPI:1083764252
Name:PETERSON, NANCY ANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:ANNE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:NANCY
Other - Middle Name:ANNE
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:5450 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-2709
Mailing Address - Country:US
Mailing Address - Phone:303-415-4250
Mailing Address - Fax:303-440-9629
Practice Address - Street 1:5495 ARAPAHOE AVE STE 100
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-1224
Practice Address - Country:US
Practice Address - Phone:303-415-4250
Practice Address - Fax:303-440-9629
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0001107363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO92222081Medicaid
P37536Medicare UPIN
COC807759Medicare PIN