Provider Demographics
NPI:1932872686
Name:PETERSON, ELIZABETH A (PA)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:JACOBSMUHLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:699 SIERRA ROSE DR STE A&B
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-2369
Mailing Address - Country:US
Mailing Address - Phone:775-204-4000
Mailing Address - Fax:
Practice Address - Street 1:805 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FERNLEY
Practice Address - State:NV
Practice Address - Zip Code:89408-9743
Practice Address - Country:US
Practice Address - Phone:775-204-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-28
Last Update Date:2025-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61188057363A00000X
NV2889363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2889OtherPA-C
WA61188057OtherPA ACTIVE
WA61188057OtherPA INTERIM LICENSE