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General NPI Number Information
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NPI Number | 1861542086
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Entity Type | Individual
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Provider Name | MICHAEL C PETERSON PA-C
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Gender | Male
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Dates
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Enumeration Date | 01/11/2007
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Last Update Date | 03/01/2021
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Provider Practice Location Address
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Address Line | LHPG MENTOR FAMILY PRACTICE 8655 MARKET STREET
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City | MENTOR
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State | OH
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Zip | 44060
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Country | US
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Telephone | 440-255-7938
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Fax | 440-255-9196
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Provider Business Mailing Address
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Address Line | 8655 MARKET STREET
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City | MENTOR
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State | OH
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Zip | 44060-9404
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Country | US
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Telephone | 440-255-7938
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Fax | 440-255-9196
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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 | 50002538
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License Number State | OH
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