Provider Demographics
NPI:1538479571
Name:PETERSON, NICOLE M (PA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:M
Other - Last Name:ALLRED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:611 W. PARK ST.
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:
Practice Address - Street 1:611 W PARK ST
Practice Address - Street 2:ED
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2500
Practice Address - Country:US
Practice Address - Phone:217-383-3313
Practice Address - Fax:217-383-4014
Is Sole Proprietor?:No
Enumeration Date:2010-10-08
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003809363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL3270614Medicare PIN
IL208905148Medicare PIN