Provider Demographics
NPI:1407913270
Name:PETERS, JACQUELINE ANN (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANN
Last Name:PETERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:742 S DAVID ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-3137
Mailing Address - Country:US
Mailing Address - Phone:307-234-9657
Mailing Address - Fax:307-234-0306
Practice Address - Street 1:1233 E 2ND ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601
Practice Address - Country:US
Practice Address - Phone:307-577-7201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036103426207L00000X
WI42785-020207L00000X
WY11648A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0161919966OtherBLUE SHIELD
IL036103426 1Medicaid
IL050090673OtherRAILROAD MEDICARE
IL131983700OtherUS DEPT OF LABOR WC
WI0036Medicare PIN
ILL93887Medicare PIN
ILH29138Medicare UPIN