Provider Demographics
NPI:1225259484
Name:PETERSON, PAULA RUTH (APRN)
Entity Type:Individual
Prefix:MS
First Name:PAULA
Middle Name:RUTH
Last Name:PETERSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 NORTH MEDICAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84113
Mailing Address - Country:US
Mailing Address - Phone:801-662-1678
Mailing Address - Fax:801-662-1676
Practice Address - Street 1:100 NORTH MEDICAL DRIVE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113
Practice Address - Country:US
Practice Address - Phone:801-662-1678
Practice Address - Fax:801-662-1676
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT181971-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT942854058211Medicaid