Healthcare Provider Details

I. General information

NPI: 1194564989
Provider Name (Legal Business Name): SARAH LAINE PETERSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2024
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5875 BREMO RD MOB SOUTH, SUITE 701
RICHMOND VA
23226-1934
US

IV. Provider business mailing address

5875 BREMO RD MOB SOUTH, SUITE 701
RICHMOND VA
23226-1934
US

V. Phone/Fax

Practice location:
  • Phone: 804-594-3130
  • Fax: 804-281-8487
Mailing address:
  • Phone: 804-594-3130
  • Fax: 804-281-8487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110010065
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: