Provider Demographics
NPI:1497911556
Name:PETERSEN, SHAUN M (PA)
Entity Type:Individual
Prefix:MR
First Name:SHAUN
Middle Name:M
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:435-890-9466
Mailing Address - Fax:
Practice Address - Street 1:2310 N 400 E
Practice Address - Street 2:STE A
Practice Address - City:NORTH LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-1788
Practice Address - Country:US
Practice Address - Phone:435-787-2000
Practice Address - Fax:435-787-1913
Is Sole Proprietor?:No
Enumeration Date:2008-07-29
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7036833-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant