Provider Demographics
NPI:1558320853
Name:PETERSON, JAY WILLIAM (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JAY
Middle Name:WILLIAM
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 1:2305 GENOA BUSINESS PARK DR
Mailing Address - Street 2:SUITE 170
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48114-7367
Mailing Address - Country:US
Mailing Address - Phone:810-299-8550
Mailing Address - Fax:810-844-0837
Practice Address - Street 1:2305 GENOA BUSINESS PARK DR
Practice Address - Street 2:SUITE 170
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-7367
Practice Address - Country:US
Practice Address - Phone:810-299-8550
Practice Address - Fax:810-844-0837
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJP004176363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D71023OtherBCBSM
MIJP004176OtherMI LICENSE #
MI0N85350Medicare ID - Type Unspecified
MI0D71023OtherBCBSM