Healthcare Provider Details

I. General information

NPI: 1184643827
Provider Name (Legal Business Name): JANE ANNETTE PETERSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 TRI PARK WAY
APPLETON WI
54914-1658
US

IV. Provider business mailing address

N288 WOODSTOCK LN
APPLETON WI
54915-3975
US

V. Phone/Fax

Practice location:
  • Phone: 920-831-0070
  • Fax: 920-831-7939
Mailing address:
  • Phone: 920-687-0769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number194-023
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: