Basic Information
| Provider Information | |||||||||
| NPI: | 1104225911 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | KATRINA | ||||||||
| MiddleName: | IRENE | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8201 EWING HALSELL DR | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782293707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105754837 | ||||||||
| FaxNumber: | 2105758647 | ||||||||
| Practice Location | |||||||||
| Address1: | 8201 EWING HALSELL DR | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782293707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105754837 | ||||||||
| FaxNumber: | 2105758647 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2014 | ||||||||
| LastUpdateDate: | 08/05/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP125582 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | AP125582 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 387414YLLW | 01 | TX | MEDICARE PTAN | OTHER | 343601601 | 05 | TX | MEDICAID |