Provider Demographics
NPI:1467672774
Name:PETERSEN, JAMES LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:LEE
Last Name:PETERSEN
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 1:1025 PENNOCK PL STE 1421
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-3257
Mailing Address - Country:US
Mailing Address - Phone:970-495-8800
Mailing Address - Fax:970-495-8820
Practice Address - Street 1:1025 PENNOCK PL STE 1421
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524
Practice Address - Country:US
Practice Address - Phone:970-495-8800
Practice Address - Fax:970-495-8820
Is Sole Proprietor?:No
Enumeration Date:2007-04-27
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1491363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO75979837Medicaid
WY126606300Medicaid
CO75979837Medicaid
COCOA104772Medicare PIN