Basic Information
| Provider Information | |||||||||
| NPI: | 1518582923 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | AMBER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10001 W INNOVATION DR STE 200 | ||||||||
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| City: | WAUWATOSA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532264851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147716780 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8500 75TH ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | PLEASANT PRAIRIE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147716780 | ||||||||
| FaxNumber: | 4142382424 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2020 | ||||||||
| LastUpdateDate: | 05/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.