Provider Demographics
NPI:1891191409
Name:PETERSON, MARLISA S (PA-C)
Entity Type:Individual
Prefix:
First Name:MARLISA
Middle Name:S
Last Name:PETERSON
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 1:325 W LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-5139
Mailing Address - Country:US
Mailing Address - Phone:803-774-7000
Mailing Address - Fax:803-774-7004
Practice Address - Street 1:325 W LIBERTY ST
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-5139
Practice Address - Country:US
Practice Address - Phone:803-774-7000
Practice Address - Fax:803-774-7004
Is Sole Proprietor?:No
Enumeration Date:2014-11-10
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant