Provider Demographics
NPI:1780678318
Name:PETERSON, PATTI LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:PATTI
Middle Name:LYNN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 PYLE DR
Mailing Address - Street 2:
Mailing Address - City:KINGSFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49802-1132
Mailing Address - Country:US
Mailing Address - Phone:906-779-7100
Mailing Address - Fax:906-779-7101
Practice Address - Street 1:1205 PYLE DR
Practice Address - Street 2:
Practice Address - City:KINGSFORD
Practice Address - State:MI
Practice Address - Zip Code:49802-1132
Practice Address - Country:US
Practice Address - Phone:906-779-7100
Practice Address - Fax:906-779-7101
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010457622084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI32569100Medicaid
MIB48655Medicare UPIN
MIN49340001Medicare ID - Type Unspecified