Provider Demographics
NPI:1083783237
Name:PETERSON, MARC R (PA)
Entity Type:Individual
Prefix:MR
First Name:MARC
Middle Name:R
Last Name:PETERSON
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 1:1515 S PHILLIPS ST
Mailing Address - Street 2:
Mailing Address - City:ALGONA
Mailing Address - State:IA
Mailing Address - Zip Code:50511-3649
Mailing Address - Country:US
Mailing Address - Phone:515-295-7714
Mailing Address - Fax:515-295-4505
Practice Address - Street 1:1515 S PHILLIPS ST
Practice Address - Street 2:
Practice Address - City:ALGONA
Practice Address - State:IA
Practice Address - Zip Code:50511-3649
Practice Address - Country:US
Practice Address - Phone:515-295-7714
Practice Address - Fax:515-295-4505
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000846363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA36656OtherWELLMARK
IA51939OtherWELLMARK
IA36656OtherWELLMARK