Provider Demographics
NPI:1568920080
Name:PETERSEN, WILEY DREW (PA-C)
Entity Type:Individual
Prefix:MR
First Name:WILEY
Middle Name:DREW
Last Name:PETERSEN
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:PO BOX 306
Mailing Address - Street 2:
Mailing Address - City:FORT HALL
Mailing Address - State:ID
Mailing Address - Zip Code:83203-0306
Mailing Address - Country:US
Mailing Address - Phone:208-238-5435
Mailing Address - Fax:208-238-5440
Practice Address - Street 1:717 MISSION RD
Practice Address - Street 2:
Practice Address - City:FORT HALL
Practice Address - State:ID
Practice Address - Zip Code:83203
Practice Address - Country:US
Practice Address - Phone:208-238-5435
Practice Address - Fax:208-238-5440
Is Sole Proprietor?:No
Enumeration Date:2019-03-04
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1714207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine