Provider Demographics
NPI:1134142151
Name:WHEELER, PETER A (PA-C)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:A
Last Name:WHEELER
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:PO BOX 4389
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32085-4389
Mailing Address - Country:US
Mailing Address - Phone:904-466-1197
Mailing Address - Fax:904-823-8967
Practice Address - Street 1:475 W TOWN PL STE 106
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092
Practice Address - Country:US
Practice Address - Phone:904-719-3327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104158363AS0400X, 363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9104158OtherFL DEPT OF HEALTH
CTP36440639OtherOXFORD
CTS53041Medicare UPIN
CT970001650Medicare ID - Type Unspecified