Provider Demographics
NPI:1194714717
Name:PETERSEN, WINSTON N (PA-C)
Entity type:Individual
Prefix:
First Name:WINSTON
Middle Name:N
Last Name:PETERSEN
Suffix:
Gender:M
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 1:811 N 900 W
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-7701
Mailing Address - Country:US
Mailing Address - Phone:801-434-7600
Mailing Address - Fax:801-434-7604
Practice Address - Street 1:800 FALLS AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3366
Practice Address - Country:US
Practice Address - Phone:208-734-6091
Practice Address - Fax:208-734-4654
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT262207-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807969000Medicaid
IDPAG40OtherBLUE CROSS OF IDAHO
IDPAG41OtherBLUE CROSS OF IDAHO
ID000010165444OtherREGENCE BLUE SHIELD
ID000010165445OtherREGENCE BLUE SHIELD OF ID
ID000010165446OtherREGENCE BLUE SHIELD OF ID
ID807969002Medicaid
IDPAG39OtherBLUE CROSS OF IDAHO
ID807969001Medicaid
ID000010165446OtherREGENCE BLUE SHIELD OF ID
IDPAG40OtherBLUE CROSS OF IDAHO
ID807969002Medicaid
ID807969000Medicaid