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General NPI Number Information
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NPI Number | 1689640948
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Entity Type | Individual
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Provider Name | SCOTT D. PETERSEN PA-C
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Gender | Male
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Dates
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Enumeration Date | 02/27/2006
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Last Update Date | 11/17/2016
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Provider Practice Location Address
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Address Line | 33300 CLEVELAND CLINIC BLVD MAIL CODE AVH4-143
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City | AVON
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State | OH
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Zip | 44011
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Country | US
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Telephone | 440-695-5449
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Fax |
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Provider Business Mailing Address
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Address Line | 33300 CLEVELAND CLINIC BLVD MAIL CODE AVH4-143
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City | AVON
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State | OH
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Zip | 44011
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Country | US
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Telephone | 440-695-5449
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 50.002138
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 85000637
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 0010-02841
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License Number State | NC
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