Provider Demographics
NPI:1245498971
Name:PETERSON, PAUL STEPHEN (PA)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:STEPHEN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5731 SILVERSTONE TER STE 100
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-3594
Mailing Address - Country:US
Mailing Address - Phone:719-636-3333
Mailing Address - Fax:719-636-0025
Practice Address - Street 1:5731 SILVERSTONE TER STE 100
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-3594
Practice Address - Country:US
Practice Address - Phone:719-636-3333
Practice Address - Fax:719-636-0025
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002714363A00000X
COPA0005173363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000687068AMedicaid
GA000687068AMedicaid