Provider Demographics
NPI:1891123543
Name:PETERSEN, HENRY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:HENRY
Middle Name:
Last Name:PETERSEN
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 1:2003 KOOTENAI HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6051
Mailing Address - Country:US
Mailing Address - Phone:208-625-5085
Mailing Address - Fax:208-625-5731
Practice Address - Street 1:700 W IRONWOOD DR
Practice Address - Street 2:STE 320
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2656
Practice Address - Country:US
Practice Address - Phone:208-625-5250
Practice Address - Fax:208-625-5251
Is Sole Proprietor?:No
Enumeration Date:2013-10-16
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1146363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical