Healthcare Provider Details

I. General information

NPI: 1063046761
Provider Name (Legal Business Name): AMANDA NICOLE PETERS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2020
Last Update Date: 01/03/2023
Certification Date: 01/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

964 W RYAN ST
BRILLION WI
54110-1076
US

IV. Provider business mailing address

PO BOX 22487
GREEN BAY WI
54305-2487
US

V. Phone/Fax

Practice location:
  • Phone: 920-756-2055
  • Fax: 920-756-3350
Mailing address:
  • Phone: 920-445-7210
  • Fax: 920-445-7289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5094
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: