Provider Demographics
NPI:1972746931
Name:PETERSEN, MICHAEL G (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:PETERSEN
Suffix:
Gender:M
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 1:7201 MANCHACA RD
Mailing Address - Street 2:STE B
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-5283
Mailing Address - Country:US
Mailing Address - Phone:512-443-3577
Mailing Address - Fax:512-445-6027
Practice Address - Street 1:7201 MANCHACA RD
Practice Address - Street 2:STE B
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-5283
Practice Address - Country:US
Practice Address - Phone:512-443-3577
Practice Address - Fax:512-445-6027
Is Sole Proprietor?:No
Enumeration Date:2009-04-07
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06055363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant