Provider Demographics
NPI:1316329378
Name:PETERSON, KARLY (PA-C)
Entity type:Individual
Prefix:
First Name:KARLY
Middle Name:
Last Name:PETERSON
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 1:505 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-5020
Mailing Address - Country:US
Mailing Address - Phone:410-341-3420
Mailing Address - Fax:410-341-3397
Practice Address - Street 1:505 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-5020
Practice Address - Country:US
Practice Address - Phone:410-341-3420
Practice Address - Fax:410-341-3397
Is Sole Proprietor?:No
Enumeration Date:2015-06-25
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0005714363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical