Provider Demographics
NPI:1306460076
Name:PETER, THERESA MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
Last Name:PETER
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 1:190 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:MI
Mailing Address - Zip Code:48457-9144
Mailing Address - Country:US
Mailing Address - Phone:810-639-2056
Mailing Address - Fax:
Practice Address - Street 1:190 E STATE ST
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:MI
Practice Address - Zip Code:48457-9144
Practice Address - Country:US
Practice Address - Phone:810-639-2056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-29
Last Update Date:2024-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009931363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant