Basic Information
| Provider Information | |||||||||
| NPI: | 1700040672 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | CRAIG | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | RPA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5500 MAIN ST | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142216755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7162043200 | ||||||||
| FaxNumber: | 7168292138 | ||||||||
| Practice Location | |||||||||
| Address1: | 5959 BIG TREE RD | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | ORCHARD PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141272291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7162043200 | ||||||||
| FaxNumber: | 7168292138 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2008 | ||||||||
| LastUpdateDate: | 03/16/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 012602 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.