Healthcare Provider Details

I. General information

NPI: 1922569698
Provider Name (Legal Business Name): ANDREA MARIE PETERSON CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MRS. ANDREA MARIE OMAN

II. Dates (important events)

Enumeration Date: 03/26/2019
Last Update Date: 02/13/2023
Certification Date: 05/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4120 PRESCOTT RD # B
MODESTO CA
95356-8418
US

IV. Provider business mailing address

4120 PRESCOTT RD # B
MODESTO CA
95356-8418
US

V. Phone/Fax

Practice location:
  • Phone: 209-544-7300
  • Fax:
Mailing address:
  • Phone: 209-544-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number95020812
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number789792
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: