Healthcare Provider Details

I. General information

NPI: 1396934238
Provider Name (Legal Business Name): JOHANNA RAE PETERSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JOHANNA RAE GODELL PA-C

II. Dates (important events)

Enumeration Date: 10/16/2007
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 NE NEFF RD STE 302
BEND OR
97701-4279
US

IV. Provider business mailing address

PO BOX 1188
CORVALLIS OR
97339-1188
US

V. Phone/Fax

Practice location:
  • Phone: 541-706-4220
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA01280
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: