Provider Demographics
NPI:1508170457
Name:PETERSEN, KATHERINE A (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:A
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 919
Mailing Address - Street 2:
Mailing Address - City:RINCON
Mailing Address - State:GA
Mailing Address - Zip Code:31326-0919
Mailing Address - Country:US
Mailing Address - Phone:912-352-0920
Mailing Address - Fax:
Practice Address - Street 1:5354 REYNOLDS ST STE 202
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-6009
Practice Address - Country:US
Practice Address - Phone:912-352-0920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-03
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA82882208600000X
KY48313207LC0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program