Provider Demographics
NPI:1477535334
Name:PETERSON, CAROLYN G (PA - C)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:G
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PA - C
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:G
Other - Last Name:EDEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:5779 E MAYO BLVD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85054-4502
Mailing Address - Country:US
Mailing Address - Phone:480-301-8000
Mailing Address - Fax:
Practice Address - Street 1:5779 E MAYO BLVD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85054-4502
Practice Address - Country:US
Practice Address - Phone:480-301-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1874363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ344458Medicaid
AZ240004028OtherRAILROAD MEDICARE
AZ86080015085259A199OtherTRIWEST
AZ86080015085259A199OtherTRIWEST
AZZPA1874Medicare PIN