1194714717 NPI number — WINSTON N PETERSEN PA-C

Table of content: WINSTON N PETERSEN PA-C (NPI 1194714717)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194714717 NPI number — WINSTON N PETERSEN PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSEN
Provider First Name:
WINSTON
Provider Middle Name:
N
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194714717
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
811 N 900 W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OREM
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84057-7701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-434-7600
Provider Business Mailing Address Fax Number:
801-434-7604

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 FALLS AVE
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
TWIN FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83301-3366
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-734-6091
Provider Business Practice Location Address Fax Number:
208-734-4654
Provider Enumeration Date:
10/17/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  262207-1206 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 807969000 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: PAG40 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: PAG41 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010165444 . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010165445 . This is a "REGENCE BLUE SHIELD OF ID" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010165446 . This is a "REGENCE BLUE SHIELD OF ID" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 807969002 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: PAG39 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 807969001 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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