MEDICARE: DAVID MORGAN 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	PA03914	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8N9127	OTHER	TX	BLUE SHIELD

General Provider Information

NPI Number	:	1801859129
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID MORGAN PETERSON PA-C

Provider Business Mailing Address
First Line	:	1395 SATTLER RD
Second Line	:	SUITE 6
City	:	CANYON LAKE
State	:	TX
Zip	:	78132-2295
Country	:	US
Telephone Number	:	830-904-4311
Fax Number	:	830-885-5541

Provider Business Practice Location Address
First Line	:	1395 SATTLER RD
Second Line	:	SUITE 6
City	:	CANYON LAKE
State	:	TX
Zip	:	78132-2295
Country	:	US
Telephone Number	:	830-904-4311
Fax Number	:	830-885-5541

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

Provider Enumeration Date	:	04/08/2006
Last Update Date	:	07/08/2007

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