Provider Demographics
NPI:1255371530
Name:PETERSON, PAMELA TERESA (NP)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:TERESA
Last Name:PETERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:DEPARTMENT 272801
Mailing Address - Street 2:PO BOX 67000
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-2728
Mailing Address - Country:US
Mailing Address - Phone:517-841-6913
Mailing Address - Fax:517-841-6917
Practice Address - Street 1:300 W WASHINGTON AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-2180
Practice Address - Country:US
Practice Address - Phone:517-841-1305
Practice Address - Fax:517-841-1306
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4704194081363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4762402Medicaid
MIP00252787OtherRR MEDICARE
MIM73310026Medicare ID - Type UnspecifiedWA FOOTE MEMORIAL
MI4762402Medicaid
S88480Medicare UPIN