Provider Demographics
NPI:1518582923
Name:PETERSON, AMBER
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10001 W INNOVATION DR STE 200
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4851
Mailing Address - Country:US
Mailing Address - Phone:414-771-6780
Mailing Address - Fax:
Practice Address - Street 1:8500 75TH ST STE 101
Practice Address - Street 2:
Practice Address - City:PLEASANT PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53158
Practice Address - Country:US
Practice Address - Phone:414-771-6780
Practice Address - Fax:414-238-2424
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-11
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant