Healthcare Provider Details

I. General information

NPI: 1093302630
Provider Name (Legal Business Name): KATHRYN PETERSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHRYN ALEXANDER

II. Dates (important events)

Enumeration Date: 12/29/2020
Last Update Date: 10/27/2025
Certification Date: 10/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 S PLUM ST
VERMILLION SD
57069-3346
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 605-677-3700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number13545
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1652
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: