Provider Demographics
NPI:1346246634
Name:PETERSON, PHYLLIS ROSE (PA)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:ROSE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:TTUHSC DEPT OF PSYCHIATRY
Mailing Address - Street 2:3601 4TH ST.
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79430-8103
Mailing Address - Country:US
Mailing Address - Phone:806-781-6069
Mailing Address - Fax:
Practice Address - Street 1:TTUHSC DEPT OF PSYCHIATRY
Practice Address - Street 2:3601 4TH ST., MS 8103
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79430-8103
Practice Address - Country:US
Practice Address - Phone:806-743-2800
Practice Address - Fax:806-743-2784
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01015363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX86N107Medicare ID - Type Unspecified