Healthcare Provider Details

I. General information

NPI: 1760454425
Provider Name (Legal Business Name): DARRYL L PETERSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 01/02/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 SAINT MARYS RD
JUNCTION CITY KS
66441-4176
US

IV. Provider business mailing address

1110 SAINT MARYS RD
JUNCTION CITY KS
66441-4176
US

V. Phone/Fax

Practice location:
  • Phone: 857-762-2585
  • Fax:
Mailing address:
  • Phone: 857-762-2585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number15-01662
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: