Basic Information
| Provider Information | |||||||||
| NPI: | 1861494486 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4189 | ||||||||
| Address2: | AUSTIN HEART | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787654189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5122064300 | ||||||||
| FaxNumber: | 5122064350 | ||||||||
| Practice Location | |||||||||
| Address1: | 2207 S CLEAR CREEK RD | ||||||||
| Address2: | STE 304 | ||||||||
| City: | KILLEEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765494132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2545262085 | ||||||||
| FaxNumber: | 2545269569 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2005 | ||||||||
| LastUpdateDate: | 10/24/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | PA01398 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 363AM0700X | PA01398 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 85N216 | 01 | TX | BC/BS | OTHER |