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General NPI Number Information
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NPI Number | 1194714717
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Entity Type | Individual
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Provider Name | WINSTON N PETERSEN PA-C
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Gender | Male
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Dates
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Enumeration Date | 10/17/2005
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Last Update Date | 04/29/2016
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Provider Practice Location Address
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Address Line | 800 FALLS AVE SUITE 2
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City | TWIN FALLS
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State | ID
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Zip | 83301-3366
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Country | US
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Telephone | 208-734-6091
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Fax | 208-734-4654
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Provider Business Mailing Address
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Address Line | 811 N 900 W
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City | OREM
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State | UT
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Zip | 84057-7701
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Country | US
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Telephone | 801-434-7600
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Fax | 801-434-7604
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 262207-1206
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License Number State | UT
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