Healthcare Provider Details

I. General information

NPI: 1093733693
Provider Name (Legal Business Name): TERRY A PETERSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 04/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 BROADWAY N
FARGO ND
58102-6704
US

IV. Provider business mailing address

2601 BROADWAY N
FARGO ND
58102-6704
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-2900
  • Fax: 701-234-2996
Mailing address:
  • Phone: 701-234-2900
  • Fax: 701-234-2996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number9599
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPAC0208
License Number StateND
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPAC0208
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: