Provider Demographics
NPI:1477532034
Name:PETERSON, MARLA (FNP/PA-C)
Entity Type:Individual
Prefix:
First Name:MARLA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:FNP/PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1419 N ACACIA AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:REEDLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93654-2197
Mailing Address - Country:US
Mailing Address - Phone:559-391-3160
Mailing Address - Fax:559-391-3162
Practice Address - Street 1:1419 N ACACIA AVE SUITE 101
Practice Address - Street 2:
Practice Address - City:REEDLEY
Practice Address - State:CA
Practice Address - Zip Code:93654-2102
Practice Address - Country:US
Practice Address - Phone:559-391-3160
Practice Address - Fax:559-391-3162
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16472363A00000X
CANP13760363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABK467ZMedicare PIN
CAA89490Medicare UPIN
CA0PA164720Medicare PIN