Provider Demographics
NPI:1720105901
Name:PETERSON, SCOTT W (PA)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:W
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:950 BOGARD RD
Mailing Address - Street 2:SUITE 233
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7105
Mailing Address - Country:US
Mailing Address - Phone:907-352-2880
Mailing Address - Fax:907-352-2885
Practice Address - Street 1:950 BOGARD RD
Practice Address - Street 2:SUITE 233
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7105
Practice Address - Country:US
Practice Address - Phone:907-352-2880
Practice Address - Fax:907-352-2885
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AK246363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKR01166Medicare UPIN
AK152656Medicare UPIN
AK152668Medicare PIN