Healthcare Provider Details

I. General information

NPI: 1942284195
Provider Name (Legal Business Name): CAROLINE PETERSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 05/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3111 GUNDERSEN DR
ONALASKA WI
54650-8447
US

IV. Provider business mailing address

1836 SOUTH AVE
LA CROSSE WI
54601-5429
US

V. Phone/Fax

Practice location:
  • Phone: 608-775-8630
  • Fax:
Mailing address:
  • Phone: 608-782-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-001150
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number1830
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: