Provider Demographics
NPI:1518950138
Name:PETERSON, JOHN A (PA C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5006 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28562-5020
Mailing Address - Country:US
Mailing Address - Phone:252-635-6446
Mailing Address - Fax:
Practice Address - Street 1:5006 LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-5020
Practice Address - Country:US
Practice Address - Phone:252-635-6446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001000034363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891036CMedicaid
NCP00473022Medicare PIN
2763493CMedicare PIN
NC2763493EMedicare PIN
NC2763493DMedicare PIN
S40943Medicare UPIN