Provider Demographics
NPI:1649207838
Name:PETERSON, RICHARD M (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:M
Last Name:PETERSON
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 1:11 JOHN STARK HWY
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:NH
Mailing Address - Zip Code:03773-1807
Mailing Address - Country:US
Mailing Address - Phone:603-863-4100
Mailing Address - Fax:603-863-8800
Practice Address - Street 1:11 JOHN STARK HWY
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:NH
Practice Address - Zip Code:03773-1807
Practice Address - Country:US
Practice Address - Phone:603-863-4100
Practice Address - Fax:603-863-8800
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0455363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30332330Medicaid
VT0AP1868Medicaid
NHAP1868Medicare PIN
S93222Medicare UPIN
NH30332330Medicaid