Provider Demographics
NPI:1285862367
Name:PETERSON II, ROBERT A (PA-C)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:PETERSON II
Suffix:
Gender:M
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 1:4110 BRIARGATE PKWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-7835
Mailing Address - Country:US
Mailing Address - Phone:719-632-7669
Mailing Address - Fax:719-632-0088
Practice Address - Street 1:4110 BRIARGATE PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-7835
Practice Address - Country:US
Practice Address - Phone:719-632-7669
Practice Address - Fax:719-632-0088
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-26
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003469363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant