Provider Demographics
NPI:1861400301
Name:PETERSON, PEGGY S (DO)
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:S
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502-2770
Mailing Address - Country:US
Mailing Address - Phone:785-539-5363
Mailing Address - Fax:785-539-5862
Practice Address - Street 1:1133 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-2770
Practice Address - Country:US
Practice Address - Phone:785-539-5363
Practice Address - Fax:785-539-5862
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0518987207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS220020955OtherRR MEDICARE
KS1000162020AMedicaid
KS220020955OtherRR MEDICARE
KS1000162020AMedicaid