Healthcare Provider Details

I. General information

NPI: 1659414449
Provider Name (Legal Business Name): MARIAN JEAN PETERS PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 05/17/2022
Certification Date: 05/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 POPLAR GROVE CONNECTOR SUITE B
BOONE NC
28607-5915
US

IV. Provider business mailing address

284 EXECUTIVE PARK DR STE 100
CONCORD NC
28025-1833
US

V. Phone/Fax

Practice location:
  • Phone: 828-264-8759
  • Fax: 828-262-5687
Mailing address:
  • Phone: 704-939-1100
  • Fax: 704-939-1173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-00240
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: