Provider Demographics
NPI:1154878692
Name:PETERSEN, DEVIN FAYE
Entity type:Individual
Prefix:
First Name:DEVIN
Middle Name:FAYE
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2995 E MIDDLETON WAY
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84124-3055
Mailing Address - Country:US
Mailing Address - Phone:801-597-6419
Mailing Address - Fax:
Practice Address - Street 1:2995 E MIDDLETON WAY
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84124-3055
Practice Address - Country:US
Practice Address - Phone:801-597-6419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTIN PROCESS363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical