Provider Demographics
NPI:1770511008
Name:PETERSON, RALPH G (PA)
Entity Type:Individual
Prefix:
First Name:RALPH
Middle Name:G
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 OAK ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-4604
Mailing Address - Country:US
Mailing Address - Phone:541-485-2357
Mailing Address - Fax:541-485-2358
Practice Address - Street 1:1410 OAK ST
Practice Address - Street 2:SUITE 200
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-4604
Practice Address - Country:US
Practice Address - Phone:541-485-2357
Practice Address - Fax:541-485-2358
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00258363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S36186Medicare UPIN
ORR130332Medicare PIN
ORRR PTAN P00227440Medicare PIN