Provider Demographics
NPI:1750541488
Name:PETERS, MICHAEL JOSEPH (PA-C)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:PETERS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2305 GENOA BUSINESS PARK DR
Mailing Address - Street 2:SUITE 170
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48114-7004
Mailing Address - Country:US
Mailing Address - Phone:810-299-8550
Mailing Address - Fax:
Practice Address - Street 1:2305 GENOA BUSINESS PARK DR
Practice Address - Street 2:SUITE 170
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-7004
Practice Address - Country:US
Practice Address - Phone:810-299-8550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-16
Last Update Date:2010-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005253363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant