Healthcare Provider Details

I. General information

NPI: 1093434870
Provider Name (Legal Business Name): ANISSA PETERSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANISSA MARTINEZ PA-C

II. Dates (important events)

Enumeration Date: 08/24/2022
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 TENEYCK ST STE 100
JACKSON MI
49201-2493
US

IV. Provider business mailing address

1 FORD PL STE 3A
DETROIT MI
48202-3450
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-8940
  • Fax: 517-205-0108
Mailing address:
  • Phone: 313-874-4806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601011567
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: