Provider Demographics
NPI:1285037929
Name:PETOSKEY, LAUREN M (PA-C)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:M
Last Name:PETOSKEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:M
Other - Last Name:BERGSTRESSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:8600 N STATE ROUTE 91
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-9541
Mailing Address - Country:US
Mailing Address - Phone:309-683-5050
Mailing Address - Fax:309-683-5335
Practice Address - Street 1:8600 N STATE ROUTE 91
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-9541
Practice Address - Country:US
Practice Address - Phone:309-683-5050
Practice Address - Fax:309-683-5335
Is Sole Proprietor?:No
Enumeration Date:2014-10-08
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-005301363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant