Provider Demographics
NPI:1720658354
Name:PETERSEN, EMILY (PA-C)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11208 W 50TH ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66203-1547
Mailing Address - Country:US
Mailing Address - Phone:913-238-7424
Mailing Address - Fax:
Practice Address - Street 1:395200 W 2900 RD
Practice Address - Street 2:
Practice Address - City:OCHELATA
Practice Address - State:OK
Practice Address - Zip Code:74051-2463
Practice Address - Country:US
Practice Address - Phone:918-535-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-27
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4779363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant