Provider Demographics
NPI:1538123088
Name:PETERSON, SUSAN M (PA)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3045 SOUTHWESTERN BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-1209
Mailing Address - Country:US
Mailing Address - Phone:716-675-7000
Mailing Address - Fax:716-674-4659
Practice Address - Street 1:3045 SOUTHWESTERN BLVD STE 104
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1209
Practice Address - Country:US
Practice Address - Phone:716-675-7000
Practice Address - Fax:716-674-4630
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007108-1363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ900092231Medicare PIN