MEDICARE: MR. CARL EDWIN PETERS PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	001490	IA

General Provider Information

NPI Number	:	1063458636
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CARL EDWIN PETERS PA

Provider Business Mailing Address
First Line	:	1551 INDIAN HILLS DR
Second Line	:
City	:	SIOUX CITY
State	:	IA
Zip	:	51104-1857
Country	:	US
Telephone Number	:	712-258-4700
Fax Number	:	712-258-4777

Provider Business Practice Location Address
First Line	:	1551 INDIAN HILLS DR
Second Line	:
City	:	SIOUX CITY
State	:	IA
Zip	:	51104-1859
Country	:	US
Telephone Number	:	712-258-4700
Fax Number	:	712-258-4777

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/21/2006
Last Update Date	:	07/08/2007

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