Provider Demographics
NPI:1619156411
Name:PETERSON, LISA M (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:TOFTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1500 14TH ST W STE 300
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-4079
Mailing Address - Country:US
Mailing Address - Phone:701-774-7500
Mailing Address - Fax:701-774-3918
Practice Address - Street 1:1500 14TH ST W STE 300
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-4079
Practice Address - Country:US
Practice Address - Phone:701-774-7500
Practice Address - Fax:701-774-3918
Is Sole Proprietor?:No
Enumeration Date:2007-10-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0377363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant