Provider Demographics
NPI:1366475204
Name:HUTTON, PEGGY SUE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:PEGGY
Middle Name:SUE
Last Name:HUTTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:PEGGY
Other - Middle Name:SUE
Other - Last Name:RICKETTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 375
Mailing Address - Street 2:850 MAIN STREET
Mailing Address - City:COALPORT
Mailing Address - State:PA
Mailing Address - Zip Code:16627-0375
Mailing Address - Country:US
Mailing Address - Phone:814-672-5141
Mailing Address - Fax:814-672-5461
Practice Address - Street 1:850 MAIN STREET
Practice Address - Street 2:
Practice Address - City:COALPORT
Practice Address - State:PA
Practice Address - Zip Code:16627
Practice Address - Country:US
Practice Address - Phone:814-672-5141
Practice Address - Fax:814-672-5461
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002999L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant