Provider Demographics
NPI:1700693397
Name:PETERSON, SHAWNA MARIE
Entity type:Individual
Prefix:
First Name:SHAWNA
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2164 MEADOWBROOK WAY
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-9329
Mailing Address - Country:US
Mailing Address - Phone:715-573-1679
Mailing Address - Fax:
Practice Address - Street 1:512 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4147
Practice Address - Country:US
Practice Address - Phone:715-847-2021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-17
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1612233363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner