MEDICARE: PAULA M PETERSON FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	504482	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	TXB110627	OTHER	TX	GROUP MEDICARE PIN
5	F057	OTHER	TX	GROUP MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	45D0703080	OTHER	TX	GROUP CLIA
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	092104103	OTHER	TX	GROUP EPSDT
6	1578514535	OTHER	TX	GROUP NPI NUMBER

General Provider Information

NPI Number	:	1568473601
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAULA M PETERSON FNP

Provider Business Mailing Address
First Line	:	2919 MARKUM DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76117-4004
Country	:	US
Telephone Number	:	817-831-0321
Fax Number	:	817-831-3211

Provider Business Practice Location Address
First Line	:	2919 MARKUM DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76117-4004
Country	:	US
Telephone Number	:	817-831-0321
Fax Number	:	817-831-3211

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2006
Last Update Date	:	09/16/2011

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Directions to “ PAULA M PETERSON FNP” Practice Location

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