Provider Demographics
NPI:1689640948
Name:PETERSEN, SCOTT D (PA-C)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:D
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 1:33300 CLEVELAND CLINIC BLVD
Mailing Address - Street 2:MAIL CODE AVH4-143
Mailing Address - City:AVON
Mailing Address - State:OH
Mailing Address - Zip Code:44011
Mailing Address - Country:US
Mailing Address - Phone:440-695-5449
Mailing Address - Fax:
Practice Address - Street 1:33300 CLEVELAND CLINIC BLVD
Practice Address - Street 2:MAIL CODE AVH4-143
Practice Address - City:AVON
Practice Address - State:OH
Practice Address - Zip Code:44011
Practice Address - Country:US
Practice Address - Phone:440-695-5449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.002138363A00000X
IL85000637363A00000X
NC0010-02841363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
R96855Medicare UPIN