Basic Information
| Provider Information | |||||||||
| NPI: | 1255426524 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSEN | ||||||||
| FirstName: | DANA | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7440 S 91ST ST | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685269797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024896555 | ||||||||
| FaxNumber: | 4023283770 | ||||||||
| Practice Location | |||||||||
| Address1: | 7440 S 91ST ST | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685269797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024896555 | ||||||||
| FaxNumber: | 4023283770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 02/01/2012 | ||||||||
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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 | 363A00000X | 902 | NE | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 902 | NE | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 10026072600 | 05 | NE | MEDICAID | 10026072000 | 05 | NE | MEDICAID | 10026072500 | 05 | NE | MEDICAID | 200598590A | 05 | KS | MEDICAID |