Provider Demographics
NPI:1568473601
Name:PETERSON, PAULA M (FNP)
Entity type:Individual
Prefix:
First Name:PAULA
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2919 MARKUM DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76117-4004
Mailing Address - Country:US
Mailing Address - Phone:817-831-0321
Mailing Address - Fax:817-831-3211
Practice Address - Street 1:2919 MARKUM DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76117-4004
Practice Address - Country:US
Practice Address - Phone:817-831-0321
Practice Address - Fax:817-831-3211
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX504482363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45D0703080OtherGROUP CLIA
TXTXB110627OtherGROUP MEDICARE PIN
TX092104102OtherGROUP MEDICAID/TPI
TX092104103OtherGROUP EPSDT
TXF057OtherGROUP MEDICARE
TX1578514535OtherGROUP NPI NUMBER