Provider Demographics
NPI:1821564360
Name:PEATROWSKY, JAMIE (PA-C)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:PEATROWSKY
Suffix:
Gender:F
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 1:395 W COUGAR BLVD STE 702
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3333
Mailing Address - Country:US
Mailing Address - Phone:801-357-3242
Mailing Address - Fax:801-357-3241
Practice Address - Street 1:395 W COUGAR BLVD STE 702
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3333
Practice Address - Country:US
Practice Address - Phone:801-357-3242
Practice Address - Fax:801-357-3241
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-23
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61144771363A00000X
NVPA2037208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty