Individual
WINSTON N PETERSEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
800 FALLS AVE, SUITE 2, TWIN FALLS, ID 83301-3366
(208) 734-6091
(208) 734-4654
Mailing address
811 N 900 W, OREM, UT 84057-7701
(801) 434-7600
(801) 434-7604
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
262207-1206
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010165444
REGENCE BLUE SHIELD
ID
01
—
000010165445
REGENCE BLUE SHIELD OF ID
ID
01
—
000010165446
REGENCE BLUE SHIELD OF ID
ID
05
—
807969000
—
ID
05
—
807969001
—
ID
05
—
807969002
—
ID
01
—
PAG39
BLUE CROSS OF IDAHO
ID
01
—
PAG40
BLUE CROSS OF IDAHO
ID
01
—
PAG41
BLUE CROSS OF IDAHO
ID
Enumeration date
10/17/2005
Last updated
04/29/2016
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