Provider Demographics
NPI:1568920080
Name:PETERSEN, WILEY D (PA-C)
Entity type:Individual
Prefix:MR
First Name:WILEY
Middle Name:D
Last Name:PETERSEN
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 1:5014 MARY LN
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202-1679
Mailing Address - Country:US
Mailing Address - Phone:208-241-5819
Mailing Address - Fax:
Practice Address - Street 1:134 W CHUBBUCK RD
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-2338
Practice Address - Country:US
Practice Address - Phone:208-417-0102
Practice Address - Fax:208-242-3219
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-04
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1714363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant