Provider Demographics
NPI:1891786166
Name:PETERSON, WENDY (PA)
Entity Type:Individual
Prefix:
First Name:WENDY
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:PO BOX 817
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57709-0817
Mailing Address - Country:US
Mailing Address - Phone:605-721-4934
Mailing Address - Fax:605-791-7704
Practice Address - Street 1:1730 HAINES AVE
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-0615
Practice Address - Country:US
Practice Address - Phone:605-721-4934
Practice Address - Fax:605-791-7704
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3581363A00000X
OK2991363A00000X
SD1004363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA97WCGXWMedicare ID - Type Unspecified
GAP34867Medicare UPIN