Provider Demographics
NPI:1417288911
Name:PETERSEN, CARLOTTA (PA)
Entity Type:Individual
Prefix:
First Name:CARLOTTA
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6750 N MACARTHUR BLVD STE 270
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039-2469
Mailing Address - Country:US
Mailing Address - Phone:877-314-8990
Mailing Address - Fax:844-364-3321
Practice Address - Street 1:500 W MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75057-3639
Practice Address - Country:US
Practice Address - Phone:877-314-8990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-22
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00598363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical