Healthcare Provider Details

I. General information

NPI: 1932190790
Provider Name (Legal Business Name): MICHELE L PEITZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 09/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 W GLYNN DR
PARKSTON SD
57366-9605
US

IV. Provider business mailing address

625 N FOSTER ST STE 108
MITCHELL SD
57301-2971
US

V. Phone/Fax

Practice location:
  • Phone: 605-928-3311
  • Fax: 605-928-4417
Mailing address:
  • Phone: 605-928-3311
  • Fax: 605-928-4417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0367
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: