Provider Demographics
NPI:1194564989
Name:PETERSON, SARAH LAINE (PA-C)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:LAINE
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 1:11200 W HUGUENOT RD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-1122
Mailing Address - Country:US
Mailing Address - Phone:877-279-5960
Mailing Address - Fax:877-384-3106
Practice Address - Street 1:11200 W HUGUENOT RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-1122
Practice Address - Country:US
Practice Address - Phone:877-279-5960
Practice Address - Fax:877-384-3106
Is Sole Proprietor?:No
Enumeration Date:2024-05-21
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110010065363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant