Provider Demographics
NPI:1316505910
Name:PETERSON, ELIZABETH JEAN (PA)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:JEAN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:JEAN
Other - Last Name:HALBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1301 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51449-1585
Mailing Address - Country:US
Mailing Address - Phone:712-464-4200
Mailing Address - Fax:
Practice Address - Street 1:1800 MAIN ST
Practice Address - Street 2:
Practice Address - City:GOWRIE
Practice Address - State:IA
Practice Address - Zip Code:50543-7438
Practice Address - Country:US
Practice Address - Phone:515-352-3891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-30
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant