Provider Demographics
NPI:1093733693
Name:PETERSON, TERRY A (PA-C)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:A
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 BROADWAY N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-6704
Mailing Address - Country:US
Mailing Address - Phone:701-234-2900
Mailing Address - Fax:701-234-2996
Practice Address - Street 1:2601 BROADWAY N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-6704
Practice Address - Country:US
Practice Address - Phone:701-234-2900
Practice Address - Fax:701-234-2996
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9599363AM0700X
NDPAC0208363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND71084Medicaid
S69872Medicare UPIN