Provider Demographics
NPI:1932190790
Name:PEITZ, MICHELE L (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:L
Last Name:PEITZ
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 1:625 N FOSTER ST
Mailing Address - Street 2:STE 108
Mailing Address - City:MITCHELL
Mailing Address - State:SD
Mailing Address - Zip Code:57301-2971
Mailing Address - Country:US
Mailing Address - Phone:605-928-3311
Mailing Address - Fax:605-928-4417
Practice Address - Street 1:401 W GLYNN DR
Practice Address - Street 2:
Practice Address - City:PARKSTON
Practice Address - State:SD
Practice Address - Zip Code:57366-9605
Practice Address - Country:US
Practice Address - Phone:605-928-3311
Practice Address - Fax:605-928-4417
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0367363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9238106OtherDAKOTACARE
SD5340340Medicaid
SD6825764Medicaid
SD4994846OtherWELLMARK TRIPP
SD5340070Medicaid
SD4994847OtherWELLMARK LAKE ANDES
SD6825765Medicaid
SD4994845OtherWELLMARK PARKSTON
SD9238106OtherDAKOTACARE
SD4994847OtherWELLMARK LAKE ANDES
SD6825765Medicaid
SDP00394909Medicare PIN