MEDICARE: JOHNATHAN L. PETERSON PA-C

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	363A00000X	Physician Assistant	PA05099	TX

General Provider Information

NPI Number	:	1568538742
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHNATHAN L. PETERSON PA-C

Provider Business Mailing Address
First Line	:	204 E FAIR OAKS PL
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-3811
Country	:	US
Telephone Number	:	210-315-4601
Fax Number	:

Provider Business Practice Location Address
First Line	:	204 E FAIR OAKS PL
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-3811
Country	:	US
Telephone Number	:	210-315-4601
Fax Number	:

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

Provider Enumeration Date	:	11/28/2006
Last Update Date	:	02/06/2025

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