Provider Demographics
NPI:1942393772
Name:PETERSON, JAMIE DUANE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JAMIE
Middle Name:DUANE
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:3799 MOMENTUM PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60689-5337
Mailing Address - Country:US
Mailing Address - Phone:231-877-3876
Mailing Address - Fax:231-775-1115
Practice Address - Street 1:927 S CARMEL ST
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-2547
Practice Address - Country:US
Practice Address - Phone:231-876-3876
Practice Address - Fax:231-775-1115
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2020-12-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5601006140363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant