Provider Demographics
NPI:1205834173
Name:PETERSON, MENDY MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MENDY
Middle Name:MARIE
Last Name:PETERSON
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 1:17030 LAKESIDE HILLS PLZ
Mailing Address - Street 2:SUITE 102
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130-2396
Mailing Address - Country:US
Mailing Address - Phone:402-758-5800
Mailing Address - Fax:402-758-5809
Practice Address - Street 1:17030 LAKESIDE HILLS PLZ
Practice Address - Street 2:SUITE 102
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130-2396
Practice Address - Country:US
Practice Address - Phone:402-758-5800
Practice Address - Fax:402-758-5809
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1874363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE099928065Medicare PIN
NE098684627Medicare PIN
COP36555Medicare Oscar/Certification