Healthcare Provider Details

I. General information

NPI: 1730611633
Provider Name (Legal Business Name): MEG PETERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2017
Last Update Date: 05/24/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5241 BUFFALO RD
ERIE PA
16510-2391
US

IV. Provider business mailing address

5241 BUFFALO RD
ERIE PA
16510-2391
US

V. Phone/Fax

Practice location:
  • Phone: 814-877-5100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA058968
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: