Basic Information
| Provider Information | |||||||||
| NPI: | 1164496212 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARR PETERSON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CARR | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | T | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7147 VISTA DR STE 150 | ||||||||
| Address2: | |||||||||
| City: | WEST DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502669317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5158759925 | ||||||||
| FaxNumber: | 5158759923 | ||||||||
| Practice Location | |||||||||
| Address1: | 1410 SW TRADITION DR STE 120 | ||||||||
| Address2: | |||||||||
| City: | ANKENY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 500239188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5158759040 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 09/08/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 001597 | IA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 001597 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 37903 | 01 | WELLMARK | OTHER | 37904 | 01 | WELLMARK | OTHER | 0634600 | 05 | IA | MEDICAID | 37905 | 01 | WELLMARK | OTHER | 3117994 | 05 | IA | MEDICAID | 37902 | 01 | WELLMARK | OTHER | 1117994 | 05 | IA | MEDICAID | 2117994 | 05 | IA | MEDICAID |