Provider Demographics
NPI:1063514628
Name:PETERSON, BRIDGET IONE (PA-C)
Entity type:Individual
Prefix:
First Name:BRIDGET
Middle Name:IONE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37-39 FERRIS AVE
Mailing Address - Street 2:APT. 16
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06854-1551
Mailing Address - Country:US
Mailing Address - Phone:720-840-8839
Mailing Address - Fax:
Practice Address - Street 1:34 MAPLE ST
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06850-3815
Practice Address - Country:US
Practice Address - Phone:203-852-2188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-03
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001806363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001806OtherLICENSE NUMBER
CTQ66725Medicare UPIN