Provider Demographics
NPI:1205946613
Name:PETERSON, SUSAN K (PA)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:11143 PARKVIEW PLAZA DR
Mailing Address - Street 2:100
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1727
Mailing Address - Country:US
Mailing Address - Phone:260-484-8830
Mailing Address - Fax:260-483-1911
Practice Address - Street 1:11143 PARKVIEW PLAZA DR
Practice Address - Street 2:100
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1727
Practice Address - Country:US
Practice Address - Phone:260-484-8830
Practice Address - Fax:260-483-1911
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN10000342A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000528371OtherANTHEM PIN
IN055770MMedicare PIN