Healthcare Provider Details

I. General information

NPI: 1164580429
Provider Name (Legal Business Name): JOHN J PETERSEN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 01/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 MEDICAL CENTER DR SUITE 201
MEDFORD OR
97504-4334
US

IV. Provider business mailing address

2620 E BARNETT RD SUITE H
MEDFORD OR
97504-8344
US

V. Phone/Fax

Practice location:
  • Phone: 541-789-5710
  • Fax:
Mailing address:
  • Phone: 541-789-5250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA00228
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: