Provider Demographics
NPI:1558593731
Name:PETERS, ROXANNE LEIGH (PA-C)
Entity Type:Individual
Prefix:
First Name:ROXANNE
Middle Name:LEIGH
Last Name:PETERS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ROXANNE
Other - Middle Name:LEIGH
Other - Last Name:THIRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:508 STOCKTRAIL AVE STE A
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82716-3582
Mailing Address - Country:US
Mailing Address - Phone:307-686-1413
Mailing Address - Fax:307-688-7940
Practice Address - Street 1:508 STOCKTRAIL AVE STE A
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-3582
Practice Address - Country:US
Practice Address - Phone:307-686-1413
Practice Address - Fax:307-688-7940
Is Sole Proprietor?:No
Enumeration Date:2009-08-20
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY479363A00000X
WYTL479363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant