Provider Demographics
NPI:1114110921
Name:PETERSEN, SHERALEE DAHLE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SHERALEE
Middle Name:DAHLE
Last Name:PETERSEN
Suffix:
Gender:F
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:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-507-3500
Mailing Address - Fax:801-507-3505
Practice Address - Street 1:5169 S COTTONWOOD ST STE 520
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6756
Practice Address - Country:US
Practice Address - Phone:801-507-3500
Practice Address - Fax:801-507-3505
Is Sole Proprietor?:No
Enumeration Date:2007-08-24
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5190165-1206363AM0700X, 363A00000X
UT5190165-4901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered