Provider Demographics
NPI:1134435209
Name:PETERSON, GLORIA LYNN (PA)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:LYNN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:GLORIA
Other - Middle Name:LYNN
Other - Last Name:RYNO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7210
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:610 S LINCOLN RD
Practice Address - Street 2:
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-1215
Practice Address - Country:US
Practice Address - Phone:906-786-6488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-26
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI363A00000X
MI5601005854363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1094325OtherNCCPA
WI1134435209Medicaid
WI078450057Medicare Oscar/Certification
MIOP383400024Medicare Oscar/Certification
WI1134435209Medicaid