Healthcare Provider Details

I. General information

NPI: 1992887376
Provider Name (Legal Business Name): TIMOTHY K. PETERSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 08/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2891 E GRANT ST
ROMA TX
78584
US

IV. Provider business mailing address

209 N CHARCO BLANCO RD APT C
RIO GRANDE CITY TX
78582-3088
US

V. Phone/Fax

Practice location:
  • Phone: 956-849-2100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA02080
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: