Provider Demographics
NPI:1740270537
Name:PETERSEN, TODD J (PA-C)
Entity type:Individual
Prefix:MR
First Name:TODD
Middle Name:J
Last Name:PETERSEN
Suffix:
Gender:M
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 1:6854 PARKER RD
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-5313
Mailing Address - Country:US
Mailing Address - Phone:314-286-6988
Mailing Address - Fax:
Practice Address - Street 1:6854 PARKER RD
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-5313
Practice Address - Country:US
Practice Address - Phone:314-286-6988
Practice Address - Fax:314-868-2561
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-002723363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q6999Medicare UPIN