Healthcare Provider Details

I. General information

NPI: 1003330036
Provider Name (Legal Business Name): EVAN DOUGLAS PETERSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2017
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6520 SE 14TH ST
DES MOINES IA
50320-1846
US

IV. Provider business mailing address

103 SW 3RD ST APT 403
DES MOINES IA
50309-4832
US

V. Phone/Fax

Practice location:
  • Phone: 515-953-1500
  • Fax: 515-953-2136
Mailing address:
  • Phone: 515-577-6220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number088343
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number088343
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: