Provider Demographics
NPI:1811406267
Name:PETERSEN, CHRISTINA STAR (PA-C)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:STAR
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CHRISTINA
Other - Middle Name:STAR
Other - Last Name:MCCANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10319 WESTLAKE DR # 130
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20817-6403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 BUREAU DRIVE BLDG 101, RM C-33, MS #1732
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20899-0001
Practice Address - Country:US
Practice Address - Phone:301-975-5131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-28
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC06578363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty