Provider Demographics
NPI:1922569698
Name:PETERSON, ANDREA MARIE (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:MRS
Other - First Name:ANDREA
Other - Middle Name:MARIE
Other - Last Name:OMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4120 PRESCOTT RD # B
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-8418
Mailing Address - Country:US
Mailing Address - Phone:209-544-7300
Mailing Address - Fax:
Practice Address - Street 1:4120 PRESCOTT RD # B
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-8418
Practice Address - Country:US
Practice Address - Phone:209-544-7300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-26
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95020812363LP0200X
CA789792208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics