Provider Demographics
NPI:1063046761
Name:PETERS, AMANDA NICOLE (PA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:NICOLE
Last Name:PETERS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7210
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:964 W RYAN ST
Practice Address - Street 2:
Practice Address - City:BRILLION
Practice Address - State:WI
Practice Address - Zip Code:54110-1076
Practice Address - Country:US
Practice Address - Phone:920-756-2055
Practice Address - Fax:920-756-3350
Is Sole Proprietor?:No
Enumeration Date:2020-03-03
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5094363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1172171OtherNATIONAL COMMISSION ON CERTIFIED PHYSICIAN ASSISTANTS