Provider Demographics
NPI:1992869721
Name:PETERSON, SUSAN WYNN (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:WYNN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MD
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 2063
Mailing Address - Street 2:SUITE A
Mailing Address - City:LEICESTER
Mailing Address - State:NC
Mailing Address - Zip Code:28748-2063
Mailing Address - Country:US
Mailing Address - Phone:828-622-0028
Mailing Address - Fax:
Practice Address - Street 1:711 NEW LEICESTER HWY
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28806-1048
Practice Address - Country:US
Practice Address - Phone:828-253-3717
Practice Address - Fax:828-252-8072
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200101115207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89129H0Medicaid
NCP00072623OtherRAILROAD MEDICARE PIN
NC89129H0Medicaid
NCP00072623OtherRAILROAD MEDICARE PIN