Provider Demographics
NPI:1164580429
Name:PETERSEN, JOHN J (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:PETERSEN
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 1:2620 E BARNETT RD
Mailing Address - Street 2:SUITE H
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8344
Mailing Address - Country:US
Mailing Address - Phone:541-789-5250
Mailing Address - Fax:
Practice Address - Street 1:520 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 201
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-4334
Practice Address - Country:US
Practice Address - Phone:541-789-5710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00228363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500613512Medicaid
ORR164473Medicare PIN