Provider Demographics
NPI:1740229913
Name:PETERSEN, COLBY B
Entity Type:Individual
Prefix:
First Name:COLBY
Middle Name:B
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:1380 E MEDICAL CENTER DR
Practice Address - Street 2:STE # 4100
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-2156
Practice Address - Country:US
Practice Address - Phone:435-251-2900
Practice Address - Fax:435-251-2901
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT370382-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000012130Medicare ID - Type UnspecifiedMEDICARE
UT000060911Medicare PIN
UTS74152Medicare UPIN