Healthcare Provider Details

I. General information

NPI: 1740270537
Provider Name (Legal Business Name): TODD J PETERSEN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 04/15/2024
Certification Date: 04/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6854 PARKER RD
FLORISSANT MO
63033-5313
US

IV. Provider business mailing address

6854 PARKER RD
FLORISSANT MO
63033-5313
US

V. Phone/Fax

Practice location:
  • Phone: 314-286-6988
  • Fax: 314-868-2561
Mailing address:
  • Phone: 314-286-6988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-002723
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: