Basic Information
| Provider Information | |||||||||
| NPI: | 1205946613 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | K. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11143 PARKVIEW PLAZA DR | ||||||||
| Address2: | 100 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604848830 | ||||||||
| FaxNumber: | 2604831911 | ||||||||
| Practice Location | |||||||||
| Address1: | 11143 PARKVIEW PLAZA DR | ||||||||
| Address2: | 100 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604848830 | ||||||||
| FaxNumber: | 2604831911 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 10/29/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 10000342A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 000000528371 | 01 | IN | ANTHEM PIN | OTHER |