Provider Demographics
NPI:1285969667
Name:PETERSEN, THUY LE (PAC)
Entity type:Individual
Prefix:
First Name:THUY
Middle Name:LE
Last Name:PETERSEN
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 1:5715 N HULL CT
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64151-2602
Mailing Address - Country:US
Mailing Address - Phone:260-418-3972
Mailing Address - Fax:
Practice Address - Street 1:1300 METROPOLITAN AVE
Practice Address - Street 2:
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048
Practice Address - Country:US
Practice Address - Phone:913-682-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-02
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1089316363AS0400X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1089316OtherMISSOURI LICENSE NUMBER