Provider Demographics
NPI:1487333548
Name:PETERSON, LORA JEAN (PA-C)
Entity type:Individual
Prefix:MISS
First Name:LORA
Middle Name:JEAN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:LORA
Other - Middle Name:PETERSON
Other - Last Name:GARRETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:15555 SPOTTED SADDLE CIR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-7984
Mailing Address - Country:US
Mailing Address - Phone:510-875-9909
Mailing Address - Fax:
Practice Address - Street 1:1697 KINGS RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6169
Practice Address - Country:US
Practice Address - Phone:904-478-5483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9114289363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical