Provider Demographics
NPI:1568538742
Name:PETERSON, JOHNATHAN L (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:L
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:21 SPURS LANE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240
Mailing Address - Country:US
Mailing Address - Phone:210-699-8326
Mailing Address - Fax:210-561-7121
Practice Address - Street 1:21 SPURS LANE
Practice Address - Street 2:SUITE 300
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240
Practice Address - Country:US
Practice Address - Phone:210-699-8326
Practice Address - Fax:210-561-7121
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2010-01-20
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical