Provider Demographics
NPI:1801859129
Name:PETERSON, DAVID MORGAN (PA-C)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MORGAN
Last Name:PETERSON
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 1:1395 SATTLER RD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:CANYON LAKE
Mailing Address - State:TX
Mailing Address - Zip Code:78132-2295
Mailing Address - Country:US
Mailing Address - Phone:830-904-4311
Mailing Address - Fax:830-885-5541
Practice Address - Street 1:1395 SATTLER RD
Practice Address - Street 2:SUITE 6
Practice Address - City:CANYON LAKE
Practice Address - State:TX
Practice Address - Zip Code:78132-2295
Practice Address - Country:US
Practice Address - Phone:830-904-4311
Practice Address - Fax:830-885-5541
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03914363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8N9127OtherBLUE SHIELD
TXP90528Medicare UPIN
TX8N9127OtherBLUE SHIELD