Provider Demographics
NPI:1164496212
Name:CARR PETERSON, MARY T (PA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:T
Last Name:CARR PETERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:T
Other - Last Name:CARR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 424
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50302-0424
Mailing Address - Country:US
Mailing Address - Phone:515-875-9255
Mailing Address - Fax:515-875-9223
Practice Address - Street 1:1410 SW TRADITION DR STE 120
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-9188
Practice Address - Country:US
Practice Address - Phone:515-875-9040
Practice Address - Fax:515-875-9041
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001597363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
37904OtherWELLMARK
IA0634600Medicaid
IA1117994Medicaid
37902OtherWELLMARK
37903OtherWELLMARK
37905OtherWELLMARK
IA2117994Medicaid
IA3117994Medicaid
37902OtherWELLMARK
37905OtherWELLMARK
I14360Medicare ID - Type Unspecified
Q33187Medicare UPIN