Provider Demographics
NPI:1619533908
Name:PETERSON, DALLIN (PA)
Entity type:Individual
Prefix:
First Name:DALLIN
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51342 NATIONAL RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIRSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43950-1710
Mailing Address - Country:US
Mailing Address - Phone:740-699-0940
Mailing Address - Fax:
Practice Address - Street 1:875 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BARNESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43713-1421
Practice Address - Country:US
Practice Address - Phone:740-484-9394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-13
Last Update Date:2025-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.009585RX363A00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician