Healthcare Provider Details

I. General information

NPI: 1326525304
Provider Name (Legal Business Name): KEVIN PATRICK PETERS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2018
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2003 KOOTENAI HEALTH WAY STE 300
COEUR D ALENE ID
83814-6051
US

IV. Provider business mailing address

4309 W MEDICAL CENTER DR STE A200
MCHENRY IL
60050-8437
US

V. Phone/Fax

Practice location:
  • Phone: 208-625-5081
  • Fax:
Mailing address:
  • Phone: 815-759-8070
  • Fax: 815-759-4931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085006652
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA-2280
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: