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General NPI Number Information
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NPI Number | 1487333548
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Entity Type | Individual
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Provider Name | LORA JEAN PETERSON PA-C
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Gender | Female
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Dates
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Enumeration Date | 07/17/2023
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Last Update Date | 07/17/2023
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Provider Practice Location Address
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Address Line | 1697 KINGS RD
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City | JACKSONVILLE
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State | FL
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Zip | 32209-6169
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Country | US
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Telephone | 904-478-5483
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Fax |
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Provider Business Mailing Address
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Address Line | 15555 SPOTTED SADDLE CIR
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City | JACKSONVILLE
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State | FL
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Zip | 32218-7984
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Country | US
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Telephone | 510-875-9909
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Fax |
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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 | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA9114289
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License Number State | FL
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