Basic Information
| Provider Information | |||||||||
| NPI: | 1528391372 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSEN | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3900 S ZINTEL WAY | ||||||||
| Address2: | |||||||||
| City: | KENNEWICK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099423627 | ||||||||
| FaxNumber: | 5099422268 | ||||||||
| Practice Location | |||||||||
| Address1: | 4804 W CLEARWATER AVE | ||||||||
| Address2: | KADLEC CLINIC URGENT CARE | ||||||||
| City: | KENNEWICK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099422355 | ||||||||
| FaxNumber: | 5092222355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2009 | ||||||||
| LastUpdateDate: | 01/22/2014 | ||||||||
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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 | 363AM0700X | PENDING | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | PA60113833 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1528391372 | 05 | WA | MEDICAID |