Provider Demographics
NPI:1285725895
Name:PETERSON, DEBRA DIANE (PAC)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:DIANE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 EAST 7TH AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926
Mailing Address - Country:US
Mailing Address - Phone:530-342-7564
Mailing Address - Fax:530-342-7585
Practice Address - Street 1:185 EAST 7TH AVE
Practice Address - Street 2:SUITE D
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926
Practice Address - Country:US
Practice Address - Phone:530-342-7564
Practice Address - Fax:530-342-7585
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15983363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPA159830Medicaid
CAOPA159830Medicare ID - Type Unspecified