Provider Demographics
NPI:1932872686
Name:PETERSON, ELIZABETH A (PA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:JACOBSMUHLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1340
Mailing Address - Street 2:
Mailing Address - City:OKANOGAN
Mailing Address - State:WA
Mailing Address - Zip Code:98840-1340
Mailing Address - Country:US
Mailing Address - Phone:509-422-5700
Mailing Address - Fax:
Practice Address - Street 1:1003 KOALA DR
Practice Address - Street 2:
Practice Address - City:OMAK
Practice Address - State:WA
Practice Address - Zip Code:98841-9247
Practice Address - Country:US
Practice Address - Phone:509-422-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-28
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61188057363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA61188057OtherPA INTERIM LICENSE