Provider Demographics
NPI:1407837727
Name:PETERSON, IVEY G (PA-C)
Entity Type:Individual
Prefix:
First Name:IVEY
Middle Name:G
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:IVEY
Other - Middle Name:
Other - Last Name:GRAHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:21475 RIDGETOP CIR
Mailing Address - Street 2:STE 150
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20166-6580
Mailing Address - Country:US
Mailing Address - Phone:703-444-5000
Mailing Address - Fax:703-444-4999
Practice Address - Street 1:21475 RIDGETOP CIR
Practice Address - Street 2:SUITE 150
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20166-6580
Practice Address - Country:US
Practice Address - Phone:703-444-5000
Practice Address - Fax:703-444-4999
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002026363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q71045Medicare UPIN
VA010891A46Medicare PIN
DC021425A53Medicare PIN