Basic Information
| Provider Information | |||||||||
| NPI: | 1861542086 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8655 MARKET STREET | ||||||||
| Address2: | |||||||||
| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440609404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402557938 | ||||||||
| FaxNumber: | 4402559196 | ||||||||
| Practice Location | |||||||||
| Address1: | LHPG MENTOR FAMILY PRACTICE | ||||||||
| Address2: | 8655 MARKET STREET | ||||||||
| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402557938 | ||||||||
| FaxNumber: | 4402559196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 03/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 50002538 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 50.002538 | 01 | OH | OHIO LICENSE | OTHER |