Provider Demographics
NPI:1861494486
Name:PETERSON, PAUL D (PA)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:D
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4189
Mailing Address - Street 2:AUSTIN HEART
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78765-4189
Mailing Address - Country:US
Mailing Address - Phone:512-206-4300
Mailing Address - Fax:512-206-4350
Practice Address - Street 1:2207 S CLEAR CREEK RD
Practice Address - Street 2:STE 304
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-4132
Practice Address - Country:US
Practice Address - Phone:254-526-2085
Practice Address - Fax:254-526-9569
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01398207RC0000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX85N216OtherBC/BS
TX8SN216Medicare ID - Type Unspecified
TX85N216Medicare PIN
TX8AS486Medicare ID - Type Unspecified
S41040Medicare UPIN