Provider Demographics
NPI:1003620485
Name:PETERSON, MICHAEL GORDON
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GORDON
Last Name:PETERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 COOPER AVE STE 4300
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-5182
Mailing Address - Country:US
Mailing Address - Phone:989-583-7460
Mailing Address - Fax:
Practice Address - Street 1:900 COOPER AVE STE 4300
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-5182
Practice Address - Country:US
Practice Address - Phone:989-583-7460
Practice Address - Fax:989-583-7432
Is Sole Proprietor?:No
Enumeration Date:2025-02-05
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704315175363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology