Provider Demographics
NPI:1821859745
Name:PETERSON, AUDREY (PA)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2825 E BARNETT RD # MSS
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8332
Mailing Address - Country:US
Mailing Address - Phone:785-313-5209
Mailing Address - Fax:
Practice Address - Street 1:691 MURPHY RD STE 107
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-4311
Practice Address - Country:US
Practice Address - Phone:541-789-5121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-18
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant