Basic Information
| Provider Information | |||||||||
| NPI: | 1255371530 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | TERESA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPARTMENT 272801 | ||||||||
| Address2: | PO BOX 67000 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482672728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178416913 | ||||||||
| FaxNumber: | 5178416917 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 W WASHINGTON AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492012180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178411305 | ||||||||
| FaxNumber: | 5178411306 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 11/27/2007 | ||||||||
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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 | 363L00000X | 4704194081 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 4762402 | 05 | MI | MEDICAID | P00252787 | 01 | MI | RR MEDICARE | OTHER |