MEDICARE: AMY K. PETERSEN D.O.

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	208000000X	Pediatrics Physician	3913	IA

General Provider Information

NPI Number	:	1730274523
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY K. PETERSEN D.O.

Provider Business Mailing Address
First Line	:	6800 LAKE DR STE 260
Second Line	:
City	:	WEST DES MOINES
State	:	IA
Zip	:	50266-2504
Country	:	US
Telephone Number	:	515-630-5022
Fax Number	:	515-630-5026

Provider Business Practice Location Address
First Line	:	6800 LAKE DR STE 260
Second Line	:
City	:	WEST DES MOINES
State	:	IA
Zip	:	50266-2504
Country	:	US
Telephone Number	:	515-630-5022
Fax Number	:	515-630-5026

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

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	07/30/2020

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