Provider Demographics
NPI:1982699799
Name:JUERGENSEN, PETER H (PA C)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:H
Last Name:JUERGENSEN
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 1:136 SHERMAN AVE
Mailing Address - Street 2:SUITE 405
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-5238
Mailing Address - Country:US
Mailing Address - Phone:203-787-0117
Mailing Address - Fax:203-777-3559
Practice Address - Street 1:136 SHERMAN AVE
Practice Address - Street 2:SUITE 405
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-5238
Practice Address - Country:US
Practice Address - Phone:203-787-0117
Practice Address - Fax:203-777-3559
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000084363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT970000823Medicare ID - Type Unspecified
S30017Medicare UPIN