Provider Demographics
NPI:1992781231
Name:PETERSON, MARY (PA)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
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:PO BOX 808
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03061-0808
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:603-595-2997
Practice Address - Street 1:460 AMHERST ST
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03063-1220
Practice Address - Country:US
Practice Address - Phone:603-883-7970
Practice Address - Fax:603-595-3652
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0390363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3073371Medicaid
NHAP1612Medicare ID - Type Unspecified
NH30331765Medicaid