Provider Demographics
NPI:1568538742
Name:PETERSON, JOHNATHAN L (PA-C)
Entity type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:L
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 E FAIR OAKS PL
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-3811
Mailing Address - Country:US
Mailing Address - Phone:210-315-4601
Mailing Address - Fax:
Practice Address - Street 1:204 E FAIR OAKS PL
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-3811
Practice Address - Country:US
Practice Address - Phone:210-315-4601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05099363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant