Healthcare Provider Details

I. General information

NPI: 1952881054
Provider Name (Legal Business Name): DIRK PEETERS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2018
Last Update Date: 03/15/2021
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 E MICHIGAN AVE STE 240
JACKSON MI
49201-1855
US

IV. Provider business mailing address

1201 E MICHIGAN AVE
JACKSON MI
49201-1852
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-1591
  • Fax:
Mailing address:
  • Phone: 517-499-6649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601008712
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: