Provider Demographics
NPI:1932872686
Name:PETERSON, ELIZABETH A (PA)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:JACOBSMUHLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1001 RIO VISTA DR
Mailing Address - Street 2:
Mailing Address - City:FALLON
Mailing Address - State:NV
Mailing Address - Zip Code:89406-5463
Mailing Address - Country:US
Mailing Address - Phone:775-423-3634
Mailing Address - Fax:775-423-4319
Practice Address - Street 1:1001 RIO VISTA DR
Practice Address - Street 2:
Practice Address - City:FALLON
Practice Address - State:NV
Practice Address - Zip Code:89406-5463
Practice Address - Country:US
Practice Address - Phone:775-423-3634
Practice Address - Fax:775-423-4319
Is Sole Proprietor?:No
Enumeration Date:2021-07-28
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61188057363A00000X
NV2889363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2889OtherPA-C
WA61188057OtherPA ACTIVE
WA61188057OtherPA INTERIM LICENSE