Provider Demographics
NPI:1386609766
Name:PETERSON, MARGARET RIDE (PA)
Entity type:Individual
Prefix:
First Name:MARGARET
Middle Name:RIDE
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 1:46 ROYAL ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02170-2112
Mailing Address - Country:US
Mailing Address - Phone:617-770-1244
Mailing Address - Fax:
Practice Address - Street 1:120 BOYLSTON ST
Practice Address - Street 2:EMERSON COLLEGE
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-4624
Practice Address - Country:US
Practice Address - Phone:617-824-8666
Practice Address - Fax:617-824-7897
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA191363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS73528Medicare UPIN
MAAP0967Medicare ID - Type Unspecified