Provider Demographics
NPI:1609847912
Name:PETERSON, GREGORY H (PA)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:H
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 323
Mailing Address - Street 2:
Mailing Address - City:BAKERSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15007-0323
Mailing Address - Country:US
Mailing Address - Phone:724-443-2442
Mailing Address - Fax:412-741-8520
Practice Address - Street 1:1099 OHIO RIVER BLVD
Practice Address - Street 2:
Practice Address - City:SEWICKLEY
Practice Address - State:PA
Practice Address - Zip Code:15143-2056
Practice Address - Country:US
Practice Address - Phone:412-741-5670
Practice Address - Fax:412-741-8520
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA000634L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAS63862Medicare UPIN
PA077895K08Medicare ID - Type Unspecified