Provider Demographics
NPI:1285278614
Name:PETERSON, HOLLY SUZANNE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:SUZANNE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 18
Mailing Address - Street 2:
Mailing Address - City:SAINT ANTHONY
Mailing Address - State:ID
Mailing Address - Zip Code:83445-0018
Mailing Address - Country:US
Mailing Address - Phone:208-356-4900
Mailing Address - Fax:208-624-4112
Practice Address - Street 1:72 S 1ST E STE 101
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1965
Practice Address - Country:US
Practice Address - Phone:208-356-4900
Practice Address - Fax:208-356-3724
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDPA-1814363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant