Provider Demographics
NPI:1710690623
Name:PETERS, KATHERINE ELISABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ELISABETH
Last Name:PETERS
Suffix:
Gender:F
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 1:120 INDEPENDENCE DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249-2628
Mailing Address - Country:US
Mailing Address - Phone:618-207-8095
Mailing Address - Fax:
Practice Address - Street 1:3437 CAROLINE ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1111
Practice Address - Country:US
Practice Address - Phone:314-977-8641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-05
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.010294363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant