Provider Demographics
NPI:1952450231
Name:PETERSON, ELIZABETH A (PA-C)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:PETERSON
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 1:100 GANNETT DRIVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106
Mailing Address - Country:US
Mailing Address - Phone:207-828-0361
Mailing Address - Fax:207-874-1483
Practice Address - Street 1:84 MARGINAL WAY
Practice Address - Street 2:SUITE 800
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101
Practice Address - Country:US
Practice Address - Phone:207-774-5816
Practice Address - Fax:207-523-8595
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA 749363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30336245Medicaid
ME431962899Medicaid
MEAP155101Medicare PIN
ME431962899Medicaid
NH30336245Medicaid
MEAP1551Medicare PIN
MEP42132Medicare UPIN